🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-02 09:24:39

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong class="Patient">Patient</strong>: Feeling nausea, having headaches, stomach infection, and pleasure is above 100 weeks. The left hand, taking deep breaths and feeling sick all the time.</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="Doctor">Doctor</strong>: The symptoms of acute pneumonia, consultation for three days, a bit less.</p></div></td></tr></tbody>

Clinical Notes

Patient Information • Patient Name: • Date of Birth: • Date of Visit: • Gender: • Patient ID:

Chief Complaint (CC): "Patient complains of feeling nausea, headaches, stomach infection, and persistent high fever for over 100 weeks. Also reports left hand pain, difficulty breathing deeply, and constant sickness."

History of Present Illness (HPI): • Onset: Not specified • Duration: Over 100 weeks • Location: Generalized • Quality: Nausea, headaches, stomach infection, fever, left hand pain, difficulty breathing • Severity: Not specified • Timing: Constant • Associated Symptoms: Nausea, headaches, stomach infection, fever, left hand pain, difficulty breathing • Aggravating/Relieving Factors: Not specified • Previous episodes: Not specified • Medications tried: Not specified • Recent Travel / Sick Contacts / Exposure: Not specified

Past Medical History (PMH): • Chronic Conditions: None provided • Past Surgeries/Hospitalizations: None provided • Allergies: None provided • Current Medications: None provided

Social History: • Smoking / Alcohol / Drug Use: Not specified • Occupation: Not specified • Living Situation: Not specified

Review of Systems (ROS): • General: Nausea, fever • ENT: Headaches • Respiratory: Difficulty breathing • GI: Stomach infection

Physical Examination (PE): • Vital Signs: Not provided • General Appearance: Not provided • HEENT: Not provided • Chest/Lungs: Not provided • Cardiovascular: Not provided • Abdomen: Not provided • Neurological: Not provided • Skin: Not provided

Assessment: • Primary Diagnosis: Symptoms suggestive of acute pneumonia • Secondary Diagnosis: None

Plan: • Investigations: Further evaluation for acute pneumonia • Medications Prescribed: Not specified • Supportive Care: Not specified • Referral: Not specified • Follow-Up: Not specified

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