🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-03 06:20:23

Transcript

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{"type": "transcription", "speaker": "Identifying", "segmentId": "47ac7709-f670-4d1d-80fd-cd3f123c4220", "text": "Doctor, I am facing some issues.", "start": "00:06", "end": "00:08", "start_sec": 6.04, "end_sec": 8.06, "roman": "Doctor, I am facing some issues.", "native": "Doctor, I am facing some issues.", "nativeScript": "Latin", "romanDiffersFromNative": false}
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Clinical Notes

Subjective

  • Patient: Ankit

  • Primary Concern: Severe headache, chest heaviness, and numbness in the left hand.

    • Reports severe headache and occasional chest heaviness.

    • Experiencing numbness in the left hand's middle finger for the past 3 to 5 days, which is painful when the palm is facing the face.

    • Pain is also present in the middle of the palm.

  • Family History:

    • Not discussed.

  • Lifestyle Factors:

    • Not discussed.

  • Reproductive History:

    • Not discussed.

  • Psychosocial Stressors:

    • Not discussed.

Objective

  • Medical History:

    • Not discussed.

  • Behavioral Observations:

    • Patient expresses concern about the symptoms and seeks clarification on what they might indicate.

Assessment

  1. Headache: Possible tension or migraine headache.

  2. Chest Heaviness: Requires further evaluation to rule out cardiac or anxiety-related causes.

  3. Numbness and Pain in Hand: Possible nerve compression or musculoskeletal issue.

Plan

  1. Diagnostics:

    • Recommend further evaluation to assess the cause of chest heaviness, possibly including an ECG or stress test.

    • Consider nerve conduction studies or imaging to evaluate hand numbness and pain.

  2. Lifestyle Modifications:

    • Encourage stress management techniques to potentially alleviate headache and chest heaviness.

  3. Symptom Management:

    • Suggest over-the-counter pain relief for headache, if appropriate.

  4. Follow-Up:

    • Schedule a follow-up appointment to review diagnostic results and adjust the treatment plan accordingly.

Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | - | – | unspecified | unspecified | unspecified | | - | – | unspecified | unspecified | unspecified | | | – | unspecified | unspecified | unspecified |

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