🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-10 07:09:55

Transcript

Doctor: Gastroenterologue, 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 ?

Clinical Notes

Subjective

  • Patient: PATIENT_NAME, unspecified age.

  • Primary Concern: Frequent abdominal pain and acid reflux.

    • Experiences abdominal pain frequently, especially after meals.

    • Reports unpleasant acid reflux.

  • Family History:

    • Not specified.

  • Lifestyle Factors:

    • Not specified.

  • Reproductive History:

    • Not specified.

  • Psychosocial Stressors:

    • Not specified.

Objective

  • Medical History:

    • Not specified.

  • Behavioral Observations:

    • Not specified.

Assessment

  1. Gastroesophageal Reflux Disease (GERD): Likely due to frequent abdominal pain and acid reflux after meals.

Plan

  1. Diagnostics:

    • Consider an upper endoscopy to assess the esophagus and stomach.

  2. Lifestyle Modifications:

    • Recommend dietary changes to identify and avoid trigger foods.

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

  3. Medications:

    • Consider prescribing proton pump inhibitors or H2 blockers to manage acid reflux.

  4. Follow-Up:

    • Schedule a follow-up appointment to evaluate the effectiveness of the treatment plan and make necessary adjustments.

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

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