Clinical Notes
AI-generated SOAP notes from voice sessions
Notes List
Budi Santoso
Review
Chest pain — Suspect angina pectoris vs. GERD
Today, 08:32 AM·12 entities·3 codes
Hendra Kusuma
Approved
Lab review — Lipid panel within normal limits
Today, 08:05 AM·8 entities·2 codes
Rizky Pratama
Approved
Knee injury — ACL strain, grade I
Today, 07:48 AM·5 entities·2 codes
Nurhayati
Review
Chronic headache — Tension-type, recurrent
Yesterday·7 entities·2 codes
Agus Setiawan
SIMRS Sent
Diabetes follow-up — HbA1c improved to 6.8%
Yesterday·10 entities·4 codes
SOAP Note — Budi Santoso
S — Subjective
Pasien laki-laki, 52 tahun, mengeluh nyeri dada sejak 3 hari yang lalu. Nyeri dirasakan terutama malam hari, sensasi seperti tertindih. Riwayat keluarga: ibu pasien memiliki hipertensi. Belum pernah pemeriksaan jantung sebelumnya.
O — Objective
TD: 145/92 mmHg · Nadi: 88x/mnt · RR: 20x/mnt · Suhu: 36.7°C
Auskultasi jantung: S1S2 reguler, murmur (-). Paru: vesikuler, rhonki (-), wheezing (-).
Auskultasi jantung: S1S2 reguler, murmur (-). Paru: vesikuler, rhonki (-), wheezing (-).
A — Assessment
1. Suspect angina pectoris — I20.9
2. DD: GERD — K21.0
3. Hipertensi grade I — I10
2. DD: GERD — K21.0
3. Hipertensi grade I — I10
P — Plan
1. Lab: CBC, Troponin I, Lipid Panel, GDS/GDP
2. ECG 12-lead stat
3. Rx: ISDN 5mg SL PRN, Aspirin 80mg 1x1
4. Rujuk kardiolog jika troponin (+)
5. Follow-up 3 hari
2. ECG 12-lead stat
3. Rx: ISDN 5mg SL PRN, Aspirin 80mg 1x1
4. Rujuk kardiolog jika troponin (+)
5. Follow-up 3 hari