🩺 Record Detail
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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><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Thanks for seeing us on short notice.</div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="SPEAKER-03">SPEAKER-03:</strong> He almost fainted last night, which is why I pushed him to come in</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="SPEAKER-01">SPEAKER-01:</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_10"><div><p><strong class="SPEAKER-02">SPEAKER-02:</strong> Yeah, I had acidity issues before, especially when I skip meals</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="SPEAKER-03">SPEAKER-03:</strong> He's been really irregular lately, sometimes keeps lunch</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="SPEAKER-03">SPEAKER-03:</strong> I keep telling him, but he just doesn't</p></div></td></tr><tr><td id="fragmentid_13"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Will he be discharged?</div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Understood. We will do an ECG and run a few blood</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I am also starting you on a proton pump inhibitor for your acidity and low dose beta blocker just to be</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> No caffeine or heavy meals for</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="SPEAKER-03">SPEAKER-03:</strong> Got it? Can you go to work or</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> He can go to work, but keep it light until we have</p></div></td></tr><tr><td id="fragmentid_19"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: I will follow up tomorrow with the test results.</div></td></tr><tr><td id="fragmentid_20"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Hi, Rohan. Welcome back.</div></td></tr><tr><td id="fragmentid_21"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: I have reviewed your ECG and blood tests.</div></td></tr><tr><td id="fragmentid_22"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Everything's within normal range. That's</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>: Few. I was getting anxious.</div></td></tr><tr><td id="fragmentid_24"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> You can relax, but your endoscopy showed my irosive</p></div></td></tr><tr><td id="fragmentid_25"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Nothing serious, but it explains the pain.</div></td></tr><tr><td id="fragmentid_26"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: So, it's not heart related?</div></td></tr><tr><td id="fragmentid_27"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: No, it's slightly acid related.</div></td></tr><tr><td id="fragmentid_28"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Irregular eating, stress, coffee, a perfect</p><p><strong class="SPEAKER-04">SPEAKER-04:</strong> too much</p></div></td></tr></tbody>
Clinical Notes
Patient Name: Roman
Date of Visit: SESSION_DATE
Time of Visit: [Time of Visit]
Presenting Complaint (CC):
Roman presents with chest discomfort that started a few days ago. He describes it as a dull pain in the middle of his chest, mostly occurring after meals or when walking fast.
History of Present Illness (HPI):
Roman denies any associated diaphoresis but reports feeling slightly breathless at times, particularly not with every episode of pain.
Family History:
Elder brother Amit mentioned that Roman almost fainted last night, prompting the visit.
Past Medical History:
Roman reports a history of acidity issues, especially when skipping meals.
Physical Examination:
Not documented.
Investigations:
ECG and blood tests were conducted, showing normal results. Endoscopy revealed erosive findings, explaining the pain.
Diagnosis:
Non-cardiac chest pain related to acidity issues.
Treatment Plan:
1. Initiation of a proton pump inhibitor for acidity management.
2. Low-dose beta-blocker prescription.
3. Advised to avoid caffeine and heavy meals.
4. Recommended to maintain a light workload until follow-up.
Follow-up Recommendations:
Scheduled for a follow-up to review test results and monitor progress.
Note: Further follow-up and management may be required based on the patient's clinical response.