Cronic Care: Scribe Insights

Patient Report

Name: Lee Smith. Age: 45. Profession: Teacher. Next Appointment: 06/20/2025.

Main Issues Report

swelling short of breath headaches

Vitals Report

Blood Pressure: 150/90 mmHg Heart Rate: 120 bpm Temperature: 101F Weight: 230 lbs Height: 5 ft 7 in BMI: 30 Respiratory Rate: 20 BPM

Anatomy Report

legs

Ros Report

- Constitutional: headaches

Lifestyle Report

Well, I do eat out a lot—mostly fast food. And I don’t really exercise much. Work has been stressful, so I snack a lot during the day. I’ve tried dieting before, but I always go back to my old habits.

Past Medical History Report

Patient: Yes, I am previously diagnosed with high blood pressure, History of Type 2 Diabetes, Hypertension, and previous appendectomy. My mother had high blood pressure, and my father had diabetes.

Plan Treatment Report

- Based on the physician's statements, the following follow-up instructions were identified: I’d like to run some tests, including a lipid panel and blood sugar levels, to check for any underlying issues Your next appointment is scheduled for 06/20/2025 I understand.
- Regarding the treatment plan, the physician mentioned the following points: (From transcript: 'But lifestyle changes—like reducing sodium intake, eating more fresh foods, and increasing physical activity—are just as important').

Overall Assessment

Overall Assessment:
Patient name is Lee Smith. Age is 45. Profession is Teacher. Next appointment is scheduled for 06/20/2025. 
Main Issues: swelling short of breath headaches
Vital Signs: Blood Pressure: 150/90 mmHg Heart Rate: 120 bpm Temperature: 101F Weight: 230 lbs Height: 5 ft 7 in BMI: 30 Respiratory Rate: 20 BPM
Lifestyle: Well, I do eat out a lot—mostly fast food. And I don’t really exercise much. Work has been stressful, so I snack a lot during the day. I’ve tried dieting before, but I always go back to my old habits.
Past & Family History: Patient: Yes, I am previously diagnosed with high blood pressure, History of Type 2 Diabetes, Hypertension, and previous appendectomy. My mother had high blood pressure, and my father had diabetes.
Plan & Treatment: - Based on the physician's statements, the following follow-up instructions were identified: I’d like to run some tests, including a lipid panel and blood sugar levels, to check for any underlying issues Your next appointment is scheduled for 06/20/2025 I understand.
- Regarding the treatment plan, the physician mentioned the following points: (From transcript: 'But lifestyle changes—like reducing sodium intake, eating more fresh foods, and increasing physical activity—are just as important').