🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-07 12:32:00

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 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

Patient Information • Patient Name: Roman • Age / DOB: N/A • Gender: N/A • Contact Number: N/A • Date of Visit: SESSION_DATE

Chief Complaint / Reason for Visit Roman presented with chest discomfort, described as a dull pain in the middle of the chest, particularly after meals or fast walking.

Medical History • Chronic Illnesses (if any): - Acidity issues • Surgeries / Hospitalizations: N/A • Current Medications: N/A • Allergies (Drugs/Food): N/A

Lifestyle Details • Smoking: N/A • Alcohol Consumption: N/A • Exercise Routine: N/A • Diet: N/A

Vital Signs Vital Reading Blood Pressure _ mmHg Pulse Rate _ bpm Temperature _ °C Respiratory Rate _ breaths/min Oxygen Saturation (SpO2) _ % Weight _ kg Height _ cm BMI _

General Physical Examination • Appearance: N/A • Eyes: N/A • Ears/Nose/Throat: N/A • Skin: N/A • Heart Sounds: N/A • Lung Sounds: N/A • Abdomen: N/A • Extremities: N/A • Neurological: N/A

Investigations (If Needed) • ☐ Blood Test • ☐ Urine Test • ☐ ECG • ☐ Chest X-Ray • ☐ Others: _____

Assessment / Diagnosis Roman's symptoms are consistent with erosive gastritis, likely induced by poor eating habits, stress, and excessive coffee consumption.

Treatment / Medications Prescribed Roman has been started on a proton pump inhibitor (PPI) and a low-dose beta-blocker. Advised to avoid caffeine and heavy meals.

Doctor's Advice & Recommendations • ☐ Healthy Diet • ☐ Regular Exercise • ☐ Hydration • ☐ Stress Management • ☐ Follow-up Visit on: SESSION_DATE

⬅ Back to History