🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-11-01 01:22:49
Transcript
I have a referral from your doctor with regards to pain on your lower tummy. Can you tell me more about this? Yeah, my lower tummy is aching. I have pain every time I eat food. After a few minutes I feel like vomiting and then when I'm not vomiting I just want to sleep and I feel very weak and tired and all my muscles are aching. How long has this been a problem? This has been going on for three days now. And how is your bowel movement? Regular. Your urinary function? Okay. What medication, what is the dose of your Ozempic and the dose for your high blood pressure medication? I take 2mg Ozempic once a week and then I take 10mg Amlodipine and I take 0.4mg Perindropil. Okay. Do you have children? I have three children. How did you deliver? I delivered them naturally. And any allergy? I am allergic to sulfonamides. What kind of allergy? I react to medication like Fancida. Okay, can you tell me a little more about your job? What kind of job do you do? I'm a real estate agent. Okay. Do you smoke cigarettes? No, I have never smoked before. Alcohol? I have never taken alcohol in my life. Do you use any recreational medication? I have never used any recreational medication. Okay. Please can you tell me a little more about your family history? Any family problem that I should know about? Family condition or disease? Okay, yes. So my mother died from cancer at 64. She had endometrial cancer and she had high blood pressure, which my father also has. He has high blood pressure and he also has a heart condition. So those are the two main things that I know we have in my family. High blood pressure and then some cancer. And my father has a heart condition. Just a very quick examination. Looking at your vital signs, your blood pressure today, about 140 over 90, which is mildly within normal limits at 98% room air. So the plan, we should order some investigation to further evaluate, including some blood tests and ultrasound scan. For now, we might need to adjust your blood pressure medication, pending when we see a good control on that. And I hope to see you back in about six weeks. Do you have any questions? So in six weeks time, would your secretary be calling me or do I have to call you back to make an appointment? You do have an option to go over to my secretary, get an appointment, or you can go and then she will contact you with a date. Is that alright? Perfect. Okay, thanks for your time today.
Clinical Notes
Allergies
Allergic to sulfonamides (e.g., Fancida).
Chief Complaints / HOPI / Examination
- Lower abdominal pain
- Nausea and vomiting after eating
- Generalized weakness and muscle aches
- Symptoms present for three days
- Regular bowel movements
- Normal urinary function
- Blood pressure: 140/90 mmHg
Provisional Diagnosis/Diagnosis:
- NA
Investigations / Medication Advised
Laboratory:
- Blood tests
Radiology:
- Ultrasound scan
Medication
| Sr. | Drug Name | Route | Dose | Frequency | Duration | Remarks |
|---|---|---|---|---|---|---|
| 1 | Ozempic | Subcutaneous | 2mg | Once a week | - | - |
| 2 | Amlodipine | Oral | 10mg | - | - | - |
| 3 | Perindopril | Oral | 0.4mg | - | - | - |
Advice / Follow-Up
- Adjust blood pressure medication as needed for better control.
- Follow up in six weeks.
- Option to contact secretary for appointment scheduling.