🩺 Record Detail
Patient Info
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 inosia, 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. 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 irregular 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's 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 castitis. 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>: 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>Doctor</strong>: Good. You need that. Continue the medication for three weeks and stick to a strict meal 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>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 castitis 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 postmanally relieved by antacids.</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong>Doctor</strong>: Okay. NSAID used Hpilori.</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong>Doctor</strong>: No. NSAID Hpilori 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 Hpilori is positive, we can start an eradication. 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 Hpilori results before escalating.</p></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 exertion, occasional breathlessness.
Dietary History:
- Typical Diet: Irregular eating habits, tendency to skip meals, frequent consumption of coffee.
Medical History:
- Acidity issues, endoscopic finding of erosive gastritis.
Medications:
- Pentaposol (proton pump inhibitor).
Allergies:
- None reported.
Social History:
- Irregular eating patterns, high coffee consumption.
Family History:
- No relevant family history mentioned.
Review of Systems (ROS):
- Gastrointestinal: History of acidity, erosive gastritis diagnosed.
Nutritional Assessment:
- BMI: Not provided.
- BMI Category: Not provided.
Body Composition Analysis: Not performed during this visit.
Dietary Intake Analysis: Not specified in the provided transcript.
Nutritional Requirements: Not specified in the provided transcript.
Nutrition Diagnosis:
- Erosive gastritis induced by poor eating habits and high coffee intake.
Diet and Meal Planning:
- Recommendations: Strict meal schedule, avoidance of spicy foods, reduced screen time before meals.
Nutritional Counseling:
- Recommendations: Emphasized importance of meal discipline and medication adherence.
Nutritional Education:
- Topics: Importance of regular meal times and avoiding triggers for gastritis.
Specialized Diet Recommendations:
- None provided.
Weight Management Strategies:
- No specific weight management discussed.
Prognosis: Good response to treatment observed, pending H. pylori results for further management decisions.
Follow-up Plan:
- Follow-up appointment pending H. pylori results.
Patient Education:
- Importance of meal discipline, avoidance of triggers, and adherence to medication for gastritis management.
Consultation Recommendations:
- Monitoring of H. pylori results for potential eradication therapy.
Referral Recommendations:
- None indicated at this time.