🩺 Record Detail
Patient Info
Transcript
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<tbody><tr><td id="fragmentid_1"><div><p><strong class="Patient">Patient</strong>: I've been drinking a lot of water lately. I feel fairly fatigued, like I will drink around three big water bottles a day and drink them really fast. And because of that, I'm using the restroom a lot. I just feel really tired and I've been feeling this way since last Monday. It's to the point where I can't sit through class because I have to get up every like 20 minutes to use the restroom. I'm also feeling really tired. I don't have the energy to do any of my homework. My mouth is dry. It's like, no matter how much I try to stay hydrated, no amount of water can fix that.</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="Doctor">Doctor</strong>: Okay, well let's take a look at your blood sugar. That's the first thing that's probably causing you to feel this way. It seems like the nurse took your blood glucose levels and you were at 360, which for a normal patient is around 80 to 120, so you definitely have high blood sugar. Do you have history of diabetics or hypoglycemia in your family?</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="Patient">Patient</strong>: My dad has type 2 diabetes, but other than that, I don't think anyone else in my family has diabetes.</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="Doctor">Doctor</strong>: Okay, well we're going to send you to an endocrinologist to get you prescribed insulin.</p></div></td></tr></tbody>
Clinical Notes
Patient Information • Patient Name: PATIENT_NAME • Date of Birth: • Date of Visit: SESSION_DATE • Gender: • Patient ID: ________
Chief Complaint (CC): "Patient complains of excessive thirst and frequent urination for the past week."
History of Present Illness (HPI): • Onset: Since last Monday • Duration: One week • Location: • Quality (e.g., sharp, dull): • Severity (scale of 1–10): • Timing (constant/intermittent): Constant • Associated Symptoms: Fatigue, dry mouth • Aggravating/Relieving Factors: • Previous episodes: • Medications tried: • Recent Travel / Sick Contacts / Exposure:
Past Medical History (PMH): • Chronic Conditions: Family history of type 2 diabetes • Past Surgeries/Hospitalizations: • Allergies: • Current Medications:
Social History: • Smoking / Alcohol / Drug Use: • Occupation: • Living Situation:
Review of Systems (ROS): • General: Fatigue • ENT: Dry mouth • Respiratory: • GI: • Others as relevant: Excessive thirst, frequent urination
Physical Examination (PE): • Vital Signs: Temp: °C, HR: __ bpm, BP: /, RR: , SpO₂: __% • General Appearance: • HEENT: • Chest/Lungs: • Cardiovascular: • Abdomen: • Neurological: • Skin:
Assessment: • Primary Diagnosis: Hyperglycemia • Secondary Diagnosis (if any):
Plan: • Investigations: Blood glucose levels • Medications Prescribed: • Supportive Care: • Referral: Endocrinologist for insulin prescription • Follow-Up: