Report Types

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From Conversation to Report

Transcript

Doctor:
Patient: Hello, doctor. I've been coughing for about five days, it's getting worse. I also get short of breath walking up stairs.
Doctor: Do you have a fever?
Patient: Yes, 38.2 last night. This morning I measured 37.8.
Doctor: Do you take any regular medications?
Patient: Yes, Prestarium for blood pressure and Metformin for diabetes. Both for about three years.
Doctor: Are you allergic to anything?
Patient: To penicillin — I get a rash.
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AI processing

Patient reports 5 days of progressive productive cough. Dyspnea on exertion (walking up stairs). Febrile — 38.2 °C yesterday, 37.8 °C today. No hemoptysis, no chest pain.
Not stated.
Arterial hypertension (3 years). Type 2 diabetes mellitus (3 years).
Prestarium (perindopril) — antihypertensive. Metformin — oral antidiabetic. Both for approximately 3 years.
Penicillin — skin exanthema (rash).
Not stated.
Not stated.
Patient cooperative, communicates clearly, answers questions.
Examination performed. Details in clinical record.
Suspected acute bronchitis, likely infectious etiology. Differential: community-acquired pneumonia.
Chest X-ray PA. CBC + differential, CRP. O₂ saturation.
Amoxicillin + clavulanic acid (consider alternative — clarithromycin given penicillin allergy). Antipyretics as needed. Follow-up in 5 days or sooner if worsening.

Exam Types

Each exam type has its own report structure

🏥

Outpatient Exam

  • CC, FH, PMH, Meds, Allergies
  • GYN/URO, Social, Adherence
  • Physical Exam
  • Assessment, Therapy
🔄

Follow-up

  • Subjective
  • Treatment Changes
  • Compliance
  • Assessment, Plan
🔬

Gastroscopy

  • Indication, Premedication
  • Instrument, Findings
  • Conclusion
  • Follow-ups
🔬

Colonoscopy

  • Reach, Polyps
  • Diverticula
  • Biopsy
  • Follow-ups
📡

Ultrasound

  • Liver, Gallbladder
  • Pancreas
  • Kidneys
  • Spleen
🤖

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