🩺 Record Detail
Patient Info
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<tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">Doctor</strong>: Good morning Rohan. I'm Dr. Meera Sharma. I understand you've 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>: Any nausea, sweating or shortness of breath when that happens.</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="SPEAKER-02">SPEAKER-02:</strong> No sweating, but yeah, sometimes I feel a little breathless, not every time,</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="SPEAKER-03">SPEAKER-03:</strong> Hi, doctor. I'm his elder brother Amit. Thanks for</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="SPEAKER-03">SPEAKER-03:</strong> He almost fainted last night, which is why I pushed him to</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I'm glad you brought him in. Rohan, do you have a history of acidity or</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="SPEAKER-02">SPEAKER-02:</strong> Yeah, I've had acidity issues before, especially when I skip meals or eat</p><p><strong class="SPEAKER-03">SPEAKER-03:</strong> late. He's been</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="SPEAKER-03">SPEAKER-03:</strong> Sometimes, he keeps lunch entirely. I keep telling him, but he just doesn't</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Understood. We'll do any CG and run a few blood tests. I'm also starting you on a proton pump inhibitor for your acidity and a low -dose beta blocker just</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> No caffeine or heavy meals for now. Got it.</p><p><strong class="SPEAKER-03">SPEAKER-03:</strong> Can he go to work or</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> He can go to work, but keep it light until we have the full picture. I'll follow up tomorrow</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>: I was getting anxious.</div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> You can relax, but your endoscopy showed mild erosive gastritis. Nothing serious,</p></div></td></tr><tr><td id="fragmentid_15"><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_16"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> No, it's likely acid -related. Irregular eating, stress, too much coffee,</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="SPEAKER-02">SPEAKER-02:</strong> Makes sense. My brother is basically on my case now</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Good. You need that. Continue the medication for three weeks and stick to a strict</p></div></td></tr><tr><td id="fragmentid_19"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Avoid spicy foods and reduce screen time before meals. It helps digestion,</p></div></td></tr><tr><td id="fragmentid_20"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Noted. Can I go back to the gym?</div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Yes. Light cardio is okay. Avoid up crunches or heavy lifting until the</p></div></td></tr><tr><td id="fragmentid_22"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Ajun, I need a quick opinion on a patient. Rohan, 28, came in with chest pain that we've now</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>: All right. What were the findings?</div></td></tr><tr><td id="fragmentid_24"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Endoscopy showed mild erosive gastritis. No bleeding or ulcers. ECG</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Pain was mostly postmeal, relieved by</p></div></td></tr><tr><td id="fragmentid_26"><div><p><strong class="SPEAKER-04">SPEAKER-04:</strong> Okay. NSAID use.</p></div></td></tr><tr><td id="fragmentid_27"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> No NSAIDs. H. Pylori is pending. He's got poor eating habits, drinks</p></div></td></tr><tr><td id="fragmentid_28"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: His brother mentioned he often skips lunch.</div></td></tr></tbody>
Clinical Notes
Clinical Notes:
Patient Name: Rohan
Date of Visit: SESSION_DATE
Chief Complaint (CC): Chest discomfort, dull pain in the middle of the chest after meals or fast walking.
Medical History:
- Acidity issues, especially when skipping meals or eating late.
Medications:
- Proton pump inhibitor for acidity.
- Low-dose beta blocker.
Assessment and Plan:
- Ordered CG and blood tests.
- Follow-up scheduled for tomorrow.
- Diagnosis of mild erosive gastritis from endoscopy.
- Advised to continue medication for three weeks.
- Recommendations: Avoid spicy foods, reduce screen time before meals, light cardio exercise allowed, avoid heavy lifting.
- Pending H. Pylori test.
Follow-up Plan:
- Follow-up appointment scheduled for tomorrow to review progress and further management.