🩺 Record Detail
Patient Info
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<tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">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 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>: And 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 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. Roman, 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 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 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="Family Member">Family Member</strong>: Will he be discharged?</p></div></td></tr><tr><td id="fragmentid_10"><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 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_11"><div><p><strong class="Family Member">Family Member</strong>: Can you 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 will follow up tomorrow with the test results.</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="Doctor">Doctor</strong>: Hi, Rohan, welcome back. I have reviewed your ECG and blood tests. Everything is within normal range.</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="Patient">Patient</strong>: That's good. Phew. I was getting anxious.</p></div></td></tr><tr><td id="fragmentid_15"><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_16"><div><p><strong class="Patient">Patient</strong>: So, it's not heart related?</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="Doctor">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_18"><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_19"><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 foods and reduce prep time before meals. It helps digestion too.</p></div></td></tr><tr><td id="fragmentid_20"><div><p><strong class="Patient">Patient</strong>: Noted. Can I go back to the gym?</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="Doctor">Doctor</strong>: Yes, light cardio is okay. Avoid ab crunches or heavy lifting until the gastritis heals.</p></div></td></tr><tr><td id="fragmentid_22"><div><p><strong class="Doctor">Doctor</strong>: Arjun, I need a quick opinion on a patient, Rohan, age 28, came in with chest pain that we have now traced back to gastritis.</p></div></td></tr><tr><td id="fragmentid_23"><div><p><strong class="Doctor">Doctor</strong>: All right. What were the findings?</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong class="Doctor">Doctor</strong>: Endoscopy showed mild erosive gastritis. No bleeding or ulcer. ECG and blood work were normal. Pain was mostly post-meal, relieved by antacids.</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong class="Doctor">Doctor</strong>: Okay, NSAID use? H-pylori?</p></div></td></tr><tr><td id="fragmentid_26"><div><p><strong class="Doctor">Doctor</strong>: No, NSAID. H-pylori is pending. He has got poor eating habits, drinks a lot of coffee. His brother mentioned he often skips lunch.</p></div></td></tr><tr><td id="fragmentid_27"><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_28"><div><p><strong class="Doctor">Doctor</strong>: Exactly. I have started pantoprazole and put him on a diet schedule. He is responding well already.</p></div></td></tr><tr><td id="fragmentid_29"><div><p><strong class="Doctor">Doctor</strong>: Good. Let's wait for H-pylori results before escalating.</p></div></td></tr></tbody>
Clinical Notes
Patient Information Patient Name: Roman DOB / Age: 28 Gender: Male Medical Record # (MRN):
Date & Time of Encounter: SESSION_DATE Provider Name: Dr. Veera Sharma
Chief Complaint (CC) Patient presents with: Chest discomfort, dull pain in the middle of the chest, mostly after meals or when walking fast.
History of Present Illness (HPI) Onset: Few days ago Location: Middle of the chest Duration: After meals or fast walking Characteristics: Dull pain Aggravating/Relieving Factors: Mostly after meals or fast walking Timing: - Severity: -
Additional Notes: Patient also experiences breathlessness occasionally.
Review of Systems (ROS) General: ☐ Fatigue ☐ Fever ☐ Weight Change ☐ Other: __ HEENT: ☐ Headache ☐ Vision Changes ☐ Sore Throat ☐ Other: _ Cardiovascular: ☐ Chest Pain ☒ Palpitations ☐ Other: _ Respiratory: ☐ Cough ☐ Shortness of Breath ☒ Other: __ Gastrointestinal: ☒ Nausea ☐ Vomiting ☐ Abdominal Pain ☐ Other: ___ Musculoskeletal: ☐ Joint Pain ☐ Muscle Weakness ☐ Other: _ Neurological: ☐ Dizziness ☐ Numbness ☐ Other: __ Psychiatric: ☐ Anxiety ☐ Depression ☐ Other: __
Past Medical History (PMH) Conditions: Acidity issues Surgeries: - Allergies: - Medications: -
Physical Examination Vital Signs: BP: _ HR: Temp: _ RR: SpO₂: ____
General Appearance: -
HEENT: -
Cardiac: -
Respiratory: -
Abdominal: -
Extremities: -
Neurological: -
Assessment Primary Diagnosis: Mild erosive gastritis
Secondary Diagnoses: -
Plan Medications: Pantoprazole, low dose beta blocker Diagnostics/Labs Ordered: ECG, blood tests Procedures: Endoscopy Referrals: - Follow-Up: Test results follow-up scheduled for tomorrow.