🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-07 12:10:18

Transcript

<thead>
                                                <tr>
                                                   <th>Original Transcription</th>
                                                </tr>
                                             </thead>
                                             <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 inausia, 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. Roman, 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 irrevolent 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 is 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 gastritis. 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>: Make 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 pre-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 gastritis 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 postman-relieved by antacids.</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong>Doctor</strong>: Okay, NSAID use H-pallori.</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong>Doctor</strong>: No, NSAID H-pallori 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 H-pallori is positive, we can start eradications. 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 H-pallori results before escalating.</p></div></td></tr></tbody>

Clinical Notes

Patient Information • Patient Name: Roman • Date of Birth: SESSION_DATE • Date of Visit: SESSION_DATE • Gender: Not specified • Patient ID: Not specified


Chief Complaint (CC): "Patient complains of chest discomfort for the past few days."


History of Present Illness (HPI): • Onset: Few days ago • Duration: - • Location: Middle of the chest • Quality (e.g., sharp, dull): Dull pain • Severity (scale of 1–10): - • Timing (constant/intermittent): Mostly after meals or when walking fast • Associated Symptoms: Breathlessness • Aggravating/Relieving Factors: After meals or walking fast • Previous episodes: - • Medications tried: - • Recent Travel / Sick Contacts / Exposure: -


Past Medical History (PMH): • Chronic Conditions: Acidity • Past Surgeries/Hospitalizations: - • Allergies: Not specified • Current Medications: Proton pump inhibitor, low dose beta blocker


Social History: • Smoking / Alcohol / Drug Use: Not specified • Occupation: Not specified • Living Situation: Not specified


Review of Systems (ROS): • General: - • ENT: - • Respiratory: - • GI: - • Others as relevant: -


Physical Examination (PE): • Vital Signs: Temp: °C, HR: __ bpm, BP: /, RR: , SpO₂: __% • General Appearance: - • HEENT: - • Chest/Lungs: - • Cardiovascular: - • Abdomen: - • Neurological: - • Skin: -


Assessment: • Primary Diagnosis: Irosive gastritis • Secondary Diagnosis (if any): -


Plan: • Investigations: ECG, blood tests, H-pylori test • Medications Prescribed: Proton pump inhibitor, diet schedule • Supportive Care: Avoid heavy meals, caffeine, spicy foods • Referral: - • Follow-Up: Await H-pylori results before further action

⬅ Back to History