🩺 Record Detail
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<tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">Doctor</strong>: Good morning, Roman. I am Dr. Veera Sharma. I understood you have been having some chest discomfort.</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="Patient">Patient</strong>: Yeah, it started a few days ago. It's like a dull pain right here in the middle of my chest, mostly after meals or when I walk fast.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="Doctor">Doctor</strong>: And inosia, sweating or shortness of breath when that happens?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="Patient">Patient</strong>: No sweating, but yeah, sometimes I feel a little breathless, not every time though.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="Family Member">Family Member</strong>: Hi, doctor. I am his elder brother Amit. Thanks for seeing us on short notice. He almost fainted last night, which is why I pushed him to come in today.</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="Doctor">Doctor</strong>: I am glad you brought him in. Do you have a history of acidity or entization?</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="Patient">Patient</strong>: Yeah, I had acidity issues before, especially when I skip meals or eat late.</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="Family Member">Family Member</strong>: He's been really irregular lately, sometimes keeps lunch entirely. I keep telling him, but he just doesn't listen. Will he be discharged?</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I am glad you brought him in. Do you have a history of acidity or entization?</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="SPEAKER-02">SPEAKER-02:</strong> Yeah, I had acidity issues before, especially when I skip meals</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="SPEAKER-03">SPEAKER-03:</strong> He's been really irregular lately, sometimes keeps lunch</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="SPEAKER-03">SPEAKER-03:</strong> I keep telling him, but he just doesn't</p></div></td></tr><tr><td id="fragmentid_13"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Will he be discharged?</div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Understood. We will do an ECG and run a few blood</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I am also starting you on a proton pump inhibitor for your acidity and low dose beta blocker just to be</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> No caffeine or heavy meals for</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="SPEAKER-03">SPEAKER-03:</strong> Got it? Can you go to work or</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> He can go to work, but keep it light until we have</p></div></td></tr><tr><td id="fragmentid_19"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: I will follow up tomorrow with the test results.</div></td></tr><tr><td id="fragmentid_20"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Hi, Rohan. Welcome back.</div></td></tr><tr><td id="fragmentid_21"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: I have reviewed your ECG and blood tests.</div></td></tr><tr><td id="fragmentid_22"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Everything's within normal range. That's</p></div></td></tr><tr><td id="fragmentid_23"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Few. I was getting anxious.</div></td></tr><tr><td id="fragmentid_24"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> You can relax, but your endoscopy showed my irosive</p></div></td></tr><tr><td id="fragmentid_25"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Nothing serious, but it explains the pain.</div></td></tr><tr><td id="fragmentid_26"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: So, it's not heart related?</div></td></tr><tr><td id="fragmentid_27"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: No, it's slightly acid related.</div></td></tr><tr><td id="fragmentid_28"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Irregular eating, stress, coffee, a perfect</p><p><strong class="SPEAKER-04">SPEAKER-04:</strong> too much</p></div></td></tr></tbody>
Clinical Notes
Clinical Notes
Patient Name: Roman
Date of Visit: SESSION_DATE
Chief Complaint (CC):
Roman presented with chest discomfort characterized as a dull pain in the middle of the chest, particularly after meals or during fast walking. He also experiences occasional breathlessness.
Medical History:
- History of acidity, especially when skipping meals or eating late.
Family History:
- Elder brother, Amit, reported concerns about Roman's irregular eating habits and episodes of almost fainting.
Assessment and Plan:
- ECG and blood tests were conducted, showing normal results.
- Endoscopy revealed erosive findings explaining the pain, which is not heart-related but associated with acidity.
- Treatment plan:
- Initiation of a proton pump inhibitor for acidity.
- Low-dose beta-blocker prescribed.
- Advised to avoid caffeine and heavy meals.
- Roman can continue working but advised to take it light until further evaluation.
Follow-up:
- Follow-up scheduled for tomorrow to review test results and adjust the treatment plan if needed.