🩺 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
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