🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-04-24 05:04:50

Transcript

[00:00 → 00:08] Hi, this is Dr. Vardhan, so how can I help you today?
[00:08 → 00:16] Hi, I have some headache from last night.
[00:16 → 00:18] So basically you have mental issues, right?
[00:18 → 00:23] I do not know, I cannot sleep.
[00:23 → 00:30] I'm sorry, Dr. Vardhan, I'm sorry, Dr. Vardhan.

Clinical Notes

Subjective

  • Patient: Complains of headache since last night.

  • Primary Concern: Difficulty sleeping.

Objective

  • No relevant data.

Assessment

  1. Headache: Present since last night.

  2. Insomnia: Difficulty sleeping reported.

Plan

  1. Symptom Management:
  2. Evaluate headache intensity and characteristics.
  3. Discuss potential triggers for headaches.
  4. Recommend sleep hygiene practices to improve sleep quality.
  5. Consider further evaluation if symptoms persist.
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