🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-07 12:11:42

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong>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>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>Doctor</strong>: And inausia, sweating or shortness of breath when that happens?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>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>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>Doctor</strong>: I am glad you brought him in. Roman, do you have a history of acidity or entization?</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong>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>Family Member</strong>: He's been really irrevolent 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>Doctor</strong>: Understood. We will do an ECG and run a few blood tests. I am also starting you on a proton pump inhibitor for your acidity and low dose beta blocker just to be safe. No caffeine or heavy meals for now. Got it?</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong>Family Member</strong>: Can you go to work or does he need rest?</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong>Doctor</strong>: He can go to work, but keep it light until we have the full picture. I will follow up tomorrow with the test results.</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong>Doctor</strong>: Hi, Rohan, welcome back. I have reviewed your ECG and blood tests. Everything is within normal range.</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong>Patient</strong>: That's good. Few. I was getting anxious.</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong>Doctor</strong>: You can relax, but your endoscopy showed my irosive gastritis. Nothing serious, but it explains the pain.</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong>Patient</strong>: So, it's not heart related?</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong>Doctor</strong>: No, it's slightly acid related. Irregular eating, stress, too much coffee, a perfect recipe.</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong>Patient</strong>: Make sense. My brother is basically on my case now for every meal.</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong>Doctor</strong>: Good, you need that. Continue the medication for three weeks and stick to a strict meal schedule. Avoid spicy foods and reduce pre-time before meals. It helps digestion too.</p></div></td></tr><tr><td id="fragmentid_19"><div><p><strong>Patient</strong>: Noted. Can I go back to the gym?</p></div></td></tr><tr><td id="fragmentid_20"><div><p><strong>Doctor</strong>: Yes, like cardio is okay. Avoid ab crunches or heavy lifting until the gastritis helps.</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong>Doctor</strong>: Arjun, I need a quick opinion on a patient, Rohan, age 28, came in with just pain that we have now traced back to gastritis.</p></div></td></tr><tr><td id="fragmentid_22"><div><p><strong>Doctor</strong>: All right. What was the findings?</p></div></td></tr><tr><td id="fragmentid_23"><div><p><strong>Doctor</strong>: Endoscopy showed my irosive gastritis. No bleeding or ulcer. ECG and blood work were normal. Pain was mostly postman-relieved by antacids.</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong>Doctor</strong>: Okay, NSAID use H-pallori.</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong>Doctor</strong>: No, NSAID H-pallori is pending. He has got poor eating habits, drinks a lot of coffee. His brother mentioned he often skips land.</p></div></td></tr><tr><td id="fragmentid_26"><div><p><strong>Doctor</strong>: Sounds like style induced. If H-pallori is positive, we can start eradications. Otherwise, PPI plus discipline should do it.</p></div></td></tr><tr><td id="fragmentid_27"><div><p><strong>Doctor</strong>: Exactly. I have started pentaposol and put him on a diet schedule. He is responding well already.</p></div></td></tr><tr><td id="fragmentid_28"><div><p><strong>Doctor</strong>: Good. Let's wait for H-pallori results before escalating.</p></div></td></tr></tbody>

Clinical Notes

Clinical Notes

  • Patient Name: Roman
  • Date of Visit: SESSION_DATE
  • CC: Chest discomfort, dull pain in the middle of the chest, worsens after meals or fast walking, occasional breathlessness.

  • HPI: Roman, a middle-aged male, presents with chest discomfort that started a few days ago. He describes the pain as dull, located in the middle of the chest, exacerbated postprandially or with exertion. He occasionally experiences breathlessness but denies sweating. His elder brother, Amit, reports a near-fainting episode prompting the visit. Roman has a history of acidity exacerbated by meal skipping or late eating.

  • Symptoms:

  • Chest discomfort: Dull, postprandial, worsens with exertion
  • Breathlessness: Occasional
  • Acidity issues: Exacerbated by meal skipping or late eating

  • Physical Exam: ECG and blood tests within normal limits.

  • Diagnosis:

  • Erosive gastritis identified via endoscopy, explaining the chest pain.

  • Plan:

  • Medications:
    • Proton pump inhibitor for acidity
    • Low-dose beta-blocker
    • Pentaprazole
  • Lifestyle Modifications:
    • Avoid caffeine and heavy meals
    • Strict meal schedule
    • Avoid spicy foods
    • Reduce pre-meal time for better digestion
  • Activity:
    • Light work allowed, cardio activities permitted
    • Avoid heavy lifting or ab crunches until gastritis improves
  • Follow-up:

    • Await H-pylori results before considering eradication therapy
    • Continue medication for three weeks
    • Follow strict dietary and lifestyle recommendations
  • Family History:

  • No relevant family history mentioned.

  • Past Medical History:

  • History of acidity

  • Medications:

  • Proton pump inhibitor
  • Low-dose beta-blocker
  • Pentaprazole

  • Investigations:

  • ECG: Normal
  • Blood tests: Normal
  • Endoscopy: Revealed erosive gastritis
  • Pending H-pylori test

  • Impression/Plan:

  • Erosive gastritis as the cause of chest discomfort
  • Await H-pylori results for further management
  • Positive response to current treatment protocol.
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