đź©ş Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-10 07:11:23

Transcript

Doctor: Bonjour, Monsieur. Je suis la dérole-fèvre, gastro-entérologue. Qu'est-ce qui vous amène aujourd'hui? Patient: Bonjour, Docteur. Je suis la jaune. Depuis quelques semaines, j'ai des douleurs abdominales fréquentes, surtout après les repas. J'ai aussi des remontées acides très désagréables. Doctor: Je vois. Avez-vous remarqué si certains aliments déclenchent plus souvent ces douleurs ou reflux? Patient: Oui. Surtout les aliments épicés, gras et parfois le café. Même le chocolat semble aggraver les choses.

Clinical Notes

Subjective

  • Patient: PATIENT_NAME

  • Primary Concern: Frequent abdominal pain and acid reflux.

    • Experiences abdominal pain frequently, especially after meals.

    • Reports unpleasant acid reflux.

  • Dietary Triggers:

    • Spicy foods, fatty foods, coffee, and chocolate seem to aggravate symptoms.

Objective

  • Medical History:

    • No specific medications mentioned in the transcript.

  • Behavioral Observations:

    • Patient is attentive to dietary triggers and is able to identify specific foods that exacerbate symptoms.

Assessment

  1. Gastroesophageal Reflux Disease (GERD): Likely due to symptoms of frequent abdominal pain and acid reflux, exacerbated by specific dietary triggers.

Plan

  1. Diagnostics:

    • Consider an endoscopy to assess the esophagus and stomach for any abnormalities.

  2. Dietary Modifications:

    • Advise avoiding spicy, fatty foods, coffee, and chocolate to reduce symptoms.

  3. Lifestyle Modifications:

    • Recommend eating smaller, more frequent meals and avoiding lying down immediately after eating.

  4. Medications:

    • Consider prescribing antacids or proton pump inhibitors to manage symptoms.

  5. Follow-Up:

    • Schedule a follow-up appointment to assess symptom management and adjust treatment as necessary.

Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | - | – | unspecified | unspecified | unspecified | | - | – | unspecified | unspecified | unspecified | | | – | unspecified | unspecified | unspecified |

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