🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2026-09-17 01:31:26

Transcript

[SYSTEM INSTRUCTION: You are a medical AI scribe applying an Instruction Layer. 1. Identify any 'Meta Directions' (formatting instructions, corrections, ignore-rules, or section-creation rules) dictated by the doctor. 2. Do NOT treat Meta Directions as clinical facts. Instead, use them as strict rules to shape the final note. 3. Apply formatting instructions (e.g., bullet points, conciseness). 4. Apply correction instructions (e.g., overriding a pain score or symptom). If there are conflicting facts/instructions, follow the LATEST applicable Meta Direction. 5. Apply ignore instructions (e.g., omit specific brand names). 6. Move information to the section explicitly requested. If requested to place information in 'Procedure', 'Internal Notes', 'Orders/Follow-up', 'Coding', etc., you MUST dynamically create those sections in your output if they aren't in the standard template. 7. Do not invent unsupported clinical information. Preserve existing normal dictation behavior. 8. Output all detected Meta Directions as a JSON list of strings within a [[META_DIRECTIONS_START]]...[[META_DIRECTIONS_END]] block at the very end of your response.
9. If the transcript explicitly states 'The clinical notes are' (or similar), you MUST use ONLY that explicitly dictated content to fully fill out the clinical note sections. Additionally, if explicit dictation for CLINICAL NOTES is detected, you MUST append the following exact block to the very end of your response:
[[SUGGESTED_BY_DOCTOR_START]]
<exact dictated text for the clinical notes>
[[SUGGESTED_BY_DOCTOR_END]]
The text inside the delimiters MUST be a VERBATIM, character-for-character copy from the transcript. Do NOT fix typos, do NOT reformat, and do NOT correct medical terms. Do NOT output 'Suggested by Doctor:' in the main text. Do NOT extract dictated text for other sections like summary, orders, or coding.]

[TRANSCRIPT]
Doctor: So can you tell me, my left thigh has been painful for almost 2 months now and how did this pain start?
Patient: It began gradually. I did not fall or injure myself. It just started as a dull ache and has been getting worse.
Doctor: And where exactly do you feel most of the pain?
Patient: Mostly in the middle of my thigh and sometimes the pain goes down towards my knee.
Doctor: Does your thigh swell up?
Patient: Yes, I have noticed some swelling and the area feels weak sometimes.
Doctor: Have you had any episodes where the leg feels weak or unstable?
Patient: Yes, occasionally it feels like it's difficult to put full weight on it.
Doctor: Do you have pain at night that wakes you up?
Patient: Yes, especially at night it's a deep constant pain.

Clinical Notes

Clinical Note

Subjective

The patient reports experiencing left thigh pain for almost 2 months. The pain began gradually without any fall or injury. It started as a dull ache and has progressively worsened. The patient feels most of the pain in the middle of the thigh, with occasional radiation towards the knee. The patient also reports swelling and weakness in the area, with episodes of difficulty bearing full weight on the leg. The pain is described as deep and constant, particularly at night, sometimes waking the patient.

Objective

No objective findings are provided in the transcript.

Assessment

The patient presents with left thigh pain, swelling, and weakness. The pain is chronic, worsening, and affects the patient's ability to bear weight. The pain is also described as deep and constant, particularly disturbing sleep at night.

Plan

No specific plan or treatment details are provided in the transcript.

[[META_DIRECTIONS_START]] [] [[META_DIRECTIONS_END]]

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