🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-07 09:49:28

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">Doctor</strong>: Good morning, Roman. I am Dr. Meera Sharma. I understood you have been having some jealous discomfort.</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="Patient">Patient</strong>: Yeah, it started a few days ago from home. 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 in India 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. No, do you have a history of anxiety or annihilation?</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 skipped meals or eight days.</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="Family Member">Family Member</strong>: He's been really irrevolent lately, sometimes keeps lunch entirely. I keep telling him, but he just doesn't listen.</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="Doctor">Doctor</strong>: Understood. We will do an ECG and run a few blood tests. I am also starting you on a protocol pump inhibitor for your acidity and low dose beta blocker just to be safe. No caffeine or heavy means for now.</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="Family Member">Family Member</strong>: But can you go to work or does he need rest?</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="Doctor">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 class="Doctor">Doctor</strong>: Hi Rohan, welcome back. I have reviewed your ECG and blood tests. Everything is within normal range, that's good.</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="Patient">Patient</strong>: Few, I was getting anxious.</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="Doctor">Doctor</strong>: You can relax, but your endoscopic showed my erosive chest type test. Nothing serious, but it explains the pain.</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="Patient">Patient</strong>: So it's not heart related?</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="Doctor">Doctor</strong>: No, it's likely acid related, irregular eating, stress, too much coffee or perfect recipe.</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="Patient">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 class="Doctor">Doctor</strong>: Good, you need that. Continue the medication for three weeks and stick to a strict meal schedule. Avoid spicy food and reduce free time to food meals. It has digestion too.</p></div></td></tr><tr><td id="fragmentid_19"><div><p><strong class="Patient">Patient</strong>: Noted. Can I go back to the gym?</p></div></td></tr><tr><td id="fragmentid_20"><div><p><strong class="Doctor">Doctor</strong>: Yes, light carding is okay. Avoid air punches or heavy lifting until the test type is hence.</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="Doctor">Doctor</strong>: Arjun, I need a quick opinion on a patient, Rohan, aged 28, came in with chest pain, that we have now raised back to chest type is.</p></div></td></tr><tr><td id="fragmentid_22"><div><p><strong class="Doctor">Doctor</strong>: All right, what were the findings?</p></div></td></tr><tr><td id="fragmentid_23"><div><p><strong class="Doctor">Doctor</strong>: Endoscopic showed my erosive chest type is, no bleeding or ulcer, ECG and blood work were normal, pain was mostly post-may relief by intensive.</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong class="Doctor">Doctor</strong>: Okay, NSAID used H-Pylorine.</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong class="Doctor">Doctor</strong>: No, NSAID H-Pylorine is pending, he has got poor eating habits, thinks a lot of coffee, his brother mentioned he often gets knocked.</p></div></td></tr><tr><td id="fragmentid_26"><div><p><strong class="Doctor">Doctor</strong>: Sounds like style induced, if H-Pylorine is fostered, we can start in medications. Otherwise, PPI plus discipline should do it.</p></div></td></tr><tr><td id="fragmentid_27"><div><p><strong class="Doctor">Doctor</strong>: Exactly, I have started Penta Prozole and put him on a diet reduced. He is this morning well already.</p></div></td></tr><tr><td id="fragmentid_28"><div><p><strong class="Doctor">Doctor</strong>: Good, let's wait for H-Pylorine results before I say anything.</p></div></td></tr></tbody>

Clinical Notes

Patient Information • Patient Name: Roman • Date of Birth: N/A • Date of Visit: SESSION_DATE • Gender: N/A • Patient ID: N/A


Chief Complaint (CC): "Patient complains of jealous discomfort for the past few days."


History of Present Illness (HPI): • Onset: Few days ago • Duration: Intermittent • Location: Middle of the chest • Quality: Dull • Severity: Not specified • Timing: Mostly after meals or when walking fast • Associated Symptoms: Breathlessness • Aggravating/Relieving Factors: After meals or walking fast • Previous episodes: Acidity issues • Medications tried: N/A • Recent Travel / Sick Contacts / Exposure: N/A


Past Medical History (PMH): • Chronic Conditions: Acidity issues • Past Surgeries/Hospitalizations: N/A • Allergies: N/A • Current Medications: N/A


Social History: • Smoking / Alcohol / Drug Use: N/A • Occupation: N/A • Living Situation: N/A


Review of Systems (ROS): • General: N/A • ENT: N/A • Respiratory: N/A • GI: Nausea, vomiting, diarrhea • Others as relevant: N/A


Physical Examination (PE): • Vital Signs: Temp: °C, HR: __ bpm, BP: /, RR: , SpO₂: __% • General Appearance: N/A • HEENT: N/A • Chest/Lungs: N/A • Cardiovascular: N/A • Abdomen: N/A • Neurological: N/A • Skin: N/A


Assessment: • Primary Diagnosis: Erosive chest pain likely due to acid-related issues • Secondary Diagnosis (if any): N/A


Plan: • Investigations: ECG, blood tests, H-Pylori test pending • Medications Prescribed: Protocol pump inhibitor (Penta Prozole), low-dose beta blocker • Supportive Care: Avoid caffeine, heavy meals, and spicy foods; stick to a strict meal schedule • Referral: N/A • Follow-Up: Await H-Pylori results before further decisions

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