🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2026-01-22 10:16:50
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
Allergies
No significant allergy history.
Chief Complaints / HOPI / Examination
- Stomachache
- Diarrhea
- Nausea
- Dizziness
- Symptoms started this morning after eating something raw yesterday evening
Provisional Diagnosis/Diagnosis:
- Indigestion
Investigations / Medication Advised
Laboratory:
- Blood test
- Urine sample
Radiology:
- NA
Medication
| Sr. | Drug Name | Route | Dose | Frequency | Duration | Remarks |
|---|---|---|---|---|---|---|
| 1 | Indigestion tablets | Oral | - | - | - | - |
Advice / Follow-Up
- Follow up after test results are available
- Rest and stay hydrated