🩺 Record Detail
Patient Info
Transcript
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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="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):
Rohan presented with chest discomfort, described as a dull pain in the middle of the chest, especially after meals or during fast walking.
Medical History:
- History of acidity issues, particularly when skipping meals or eating late.
Family History:
- Elder brother, Amit, accompanying Rohan to the appointment.
Assessment and Plan:
- Ordered ECG and blood tests.
- Started Rohan on a proton pump inhibitor for acidity and a low-dose beta blocker.
- Advised against caffeine and heavy meals.
- Endoscopy revealed mild erosive gastritis, explaining the pain.
- No serious heart-related concerns identified.
- Medication regimen to continue for three weeks.
- Recommendations to avoid spicy foods, reduce screen time before meals, and maintain a strict diet.
- Light cardio exercise permitted; advised against crunches or heavy lifting.
- Pending H. Pylori testing due to poor eating habits and irregular meal patterns.
- Follow-up scheduled for test results and further evaluation.