🩺 Record Detail
Patient Info
Transcript
Patient: I have cramps. I've been having cramps for five days. My period was yesterday and I need painkillers to take the cramps away. It's been hurting so bad.
Clinical Notes
Subjective
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Patient: PATIENT_NAME, unspecified age.
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Primary Concern: Cramps.
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Experiencing cramps for five days.
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Period started yesterday, causing significant pain.
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Family History:
- Not mentioned.
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Lifestyle Factors:
- Not mentioned.
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Reproductive History:
- Recent menstrual period began yesterday.
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Psychosocial Stressors:
- Not mentioned.
Objective
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Medical History:
- Not mentioned.
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Behavioral Observations:
- Patient reports severe pain due to menstrual cramps.
Assessment
- Menstrual Cramps: Likely primary dysmenorrhea given the timing with menstrual cycle.
Plan
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Pain Management:
- Prescribe appropriate painkillers for cramp relief.
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Follow-Up:
- Schedule a follow-up if pain persists beyond typical menstrual cycle duration.
Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | - | – | unspecified | unspecified | unspecified | | - | – | unspecified | unspecified | unspecified | | | – | unspecified | unspecified | unspecified |