AI-generated before the patient enters the room. Doctor sees this on their screen as the patient walks in.
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Thomas Varghese
52 years · Male · UHID-2024-00391
Neurosurgery · Token A009 · Today 09:41 AM
Surgical opinion
AI category
Chief Complaint
Severe headache with radiation to neck, progressively worsening over 3 weeks. Associated dizziness and intermittent blurring of vision in the left eye.
History of Present Illness
Onset 3 weeks ago, initially mild, now rated 8/10 on pain scale. Symptoms are worse in the mornings. No fever or vomiting. No recent trauma. Patient has brought MRI Brain + Spine (dated 2 weeks ago) from referring hospital. Referred by Dr. Suresh Menon, General Medicine, Ernakulam.
Current Medications
Tab. Paracetamol 500mg SOS Tab. Pantoprazole 40mg OD Tab. Amlodipine 5mg OD
Allergies
NKDA — No known drug allergies
Relevant Past History
Hypertension — on treatment · No diabetes · No prior surgeries · Non-smoker · No family history of malignancy
AI Flags for Doctor
MRI available — upload pendingSurgical candidate — likely admissionReferral letter attachedFinancial counseling may be neededSurgical coordinator not yet alerted
Patient's Own Words
"I have had a severe headache for the past three weeks. The pain is mostly at the back of my head and goes into my neck. It is worse in the morning. I also feel dizzy sometimes and my vision gets blurry on the left side. I have brought my MRI scan from the previous hospital."
Coordinator Actions
📤
Upload patient MRI
📋
Alert surgical coordinator
🏥
Prepare admission form
💬
Schedule financial counseling
Previous Visits
12 Jan 2024
General Medicine — Hypertension review
03 Sep 2023
Ophthalmology — Vision check
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OPD Admission Card
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Thomas Varghese
Token A009 · Neurosurgery OPD
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GPT-4 Medical Correction Prompt
Correct spelling & grammar only · Keep all original content · Add units to lab values (mg/dL, mmol/L, mm Hg, g/dL, bpm) · Number investigation results · No hallucination · Mark unclear values as [unclear] but never delete.