🩺 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="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'm 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'm glad you brought him in. Rohan, do you have a history of acidity or indigestion?</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="Patient">Patient</strong>: Yeah, I've 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, he skips 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="Patient">Patient</strong>: Guilty as charged.</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="Doctor">Doctor</strong>: Understood. We'll do an ECG 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 to be safe. No caffeine or heavy meals for now.</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="Patient">Patient</strong>: Got it. Can he go to work or does he need rest?</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="Doctor">Doctor</strong>: He can go to work, but keep it light until we have the full picture. I'll follow up tomorrow with the test results.</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="Patient">Patient</strong>: 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 endoscopy showed mild erosive gastritis. 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, a perfect recipe.</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="Patient">Patient</strong>: Makes 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's schedule. Avoid spicy foods and reduce screen time before meals. It helps 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 cardio is okay. Avoid crunches or heavy lifting until the gastritis heals.</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="Doctor">Doctor</strong>: Ajun, I need a quick opinion on a patient. Rohan, 28, came in with chest pain that we've now traced back to gastritis.</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>: Endoscopy showed mild erosive gastritis. No bleeding or ulcers. ECG and blood work were normal. Pain was mostly postmeal, relieved by antacids.</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong class="Doctor">Doctor</strong>: Okay. NSAID use. H. Pylori.</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong class="Doctor">Doctor</strong>: No NSAIDs. H. Pylori is pending. He's got poor eating habits, drinks a lot of coffee. His brother mentioned he often skips lunch.</p></div></td></tr><tr><td id="fragmentid_26"><div><p><strong class="Doctor">Doctor</strong>: Sounds lifestyle-induced. If H. Pylori is positive, we can start eradication. 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've started pantoprazole and put him on a diet schedule. He's responding well already.</p></div></td></tr><tr><td id="fragmentid_28"><div><p><strong class="Doctor">Doctor</strong>: Good. Let's wait for the H. Pylori results before escalating.</p></div></td></tr></tbody>
Clinical Notes
Clinical Notes
Patient Name: Rohan
Date of Visit: SESSION_DATE
Chief Complaint (CC):
Rohan presented with chest discomfort, described as a dull pain in the middle of the chest, exacerbated after meals or brisk walking.
Medical History:
History of acidity and indigestion, particularly triggered by irregular eating habits and late meals.
Family History:
Elder brother Amit mentioned Rohan's irregular eating patterns, including skipping lunch.
Diagnosis and Treatment:
- Diagnosis: Mild erosive gastritis identified through endoscopy.
- Treatment Plan:
- Initiated on pantoprazole for acidity.
- Advised to follow a strict meal schedule, avoid spicy foods, reduce coffee intake, and limit screen time before meals.
- Light cardio exercise permitted, avoiding heavy lifting until gastritis heals.
Follow-up:
- Follow-up scheduled for test results and further evaluation.
- Pending H. Pylori test to determine the need for eradication therapy.
Recommendations:
- Emphasized the importance of disciplined eating habits and adherence to medication for three weeks.
- Encouraged to continue light cardio exercise and avoid strenuous activities until gastritis resolves.
Referral Recommendations:
No referrals indicated at this time.