🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-03 06:19:02

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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{"type": "transcription", "speaker": "Identifying", "segmentId": "b580bb43-9ae0-413b-983e-c667f6d12c07", "text": "And from past 3 to 5 days, I am feeling numbness in my left hand's middle finger.", "start": "00:20", "end": "00:26", "start_sec": 20.1, "end_sec": 26.06, "roman": "And from past 3 to 5 days, I am feeling numbness in my left hand's middle finger.", "native": "And from past 3 to 5 days, I am feeling numbness in my left hand's middle finger.", "nativeScript": "Latin", "romanDiffersFromNative": false}
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Clinical Notes

Subjective

  • Patient: Ankit, age unspecified.

  • Primary Concern: Severe headache, chest heaviness, and numbness.

    • Reports severe headache and occasional chest heaviness.

    • Experiencing numbness in the left hand's middle finger for the past 3 to 5 days, with associated pain when the palm faces the face.

    • Pain noted in the middle of the palm.

  • Family History: Not provided.

  • Lifestyle Factors: Not provided.

  • Reproductive History: Not provided.

  • Psychosocial Stressors: Not provided.

Objective

  • Medical History: Not provided.

  • Behavioral Observations: Patient reports symptoms of headache, chest heaviness, and numbness with pain in the hand.

Assessment

  1. Headache: Severe headache requires further evaluation to determine underlying cause.

  2. Chest Heaviness: Occasional heaviness in the chest needs to be assessed for potential cardiac or respiratory issues.

  3. Numbness and Pain in Hand: Symptoms suggest possible nerve compression or other neurological issues.

Plan

  1. Diagnostics:

    • Recommend neurological evaluation to assess numbness and pain in the hand.

    • Consider imaging studies if symptoms persist or worsen.

  2. Lifestyle Modifications:

    • Encourage monitoring of symptoms and avoiding activities that exacerbate numbness and pain.

  3. Symptom Management:

    • Suggest over-the-counter pain relief for headache as needed, unless contraindicated.

  4. Follow-Up:

    • Schedule follow-up appointment to reassess symptoms and evaluate the effectiveness of any interventions.

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

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