🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2026-01-22 10:08:11
Transcript
Doctor: Good morning, please have a seat here. What's the problem? Patient: I have a terrible stomachache. Doctor: Do you have diarrhea? Patient: Yes, I do. Doctor: Do you have any other symptoms? Patient: Yes, I feel sick. Doctor: You mean you feel nauseous? Patient: That's right. I feel like vomiting and right now I feel dizzy too. Doctor: When did the symptoms start? Patient: This morning. Yesterday evening I ate something raw. Doctor: All right, please take off your clothes to the waist and lie down there. Just tell me if it hurts when I do this. Patient: It doesn't hurt. Ouch! It hurts there. Doctor: Okay, let's hope it's just indigestion, but we'll need to run some diagnostic tests to be sure. We'll run a blood test and we'll also need a urine sample. Patient: Can you give me something for the time being? Doctor: Yes, I'll give you a prescription for indigestion tablets.
Clinical Notes
Pediatric Consultation Template
Patient Information:
- Name: PATIENT_NAME
- Age:
- Sex:
- Date of Birth:
- Parent/Guardian Name:
- Date of Consultation: SESSION_DATE
- Referring Physician (if any):
Chief Complaint:
"Terrible stomachache and diarrhea"
History of Present Illness (HPI):
- Onset: Symptoms started this morning
- Duration: Since this morning
- Progression: Patient reports feeling nauseous, like vomiting, and dizzy
- Associated symptoms: Diarrhea, nausea, dizziness
- Any home treatments or medications given: None mentioned
- Response to treatments so far: N/A
Past Medical History:
- Previous illnesses/hospitalizations: Not discussed
- Birth history (term/preterm, complications): Not discussed
- Growth and development milestones: Not discussed
- Immunization status (Up to date/Delayed): Not discussed
- Allergies (Drug/Food/Other): Not discussed
Family History:
- Any hereditary or chronic illnesses (asthma, diabetes, etc.): Not discussed
Social History:
- Attends school/daycare: Not discussed
- Exposure to smokers or sick contacts: Not discussed
- Family environment: Not discussed
Review of Systems (ROS):
- General: Nausea, dizziness
- ENT: Not discussed
- Respiratory: Not discussed
- GI: Stomachache, diarrhea, nausea, vomiting
- GU: Not discussed
- Skin: Not discussed
- Neurological: Dizziness
Physical Examination:
| System | Findings |
General Appearance (Active, ill-looking, well-nourished)
| Vitals | Temp: ___ °C, HR: , RR: , BP: , SpO₂: % |
| HEENT | (Normal/Red throat, Ear discharge, etc.) |
| Chest | (Clear breath sounds, Wheeze, Crackles) |
| Cardiovascular | (Normal S1/S2, murmurs) |
| Abdomen | Tenderness noted on examination |
| CNS | (Alert, oriented, reflexes) |
| Skin | (Rashes, bruises) |
Assessment / Diagnosis:
Possible indigestion
Plan / Recommendations:
- Investigations Ordered: Blood test, Urine sample
- Medications Prescribed: Indigestion tablets
- Advice to Parents: Monitor symptoms, ensure hydration
- Follow-up: Return if symptoms worsen or do not improve