Medical Scribe Demo

Summary

In this engaging dialogue, a patient recounts their troubling experience with severe belly pain following a meal of sweet and sour chicken from a Chinese restaurant. Initially dismissed as indigestion, the pain worsens, accompanied by symptoms like vomiting and diarrhea. The healthcare provider conducts a thorough examination, expressing concern about the patient's heart health and suggesting a series of tests, including an EKG and blood work. The conversation highlights the importance of addressing gastrointestinal issues promptly while navigating the complexities of patient care and medical evaluation.

Takeaways

• 😀 The patient experienced abdominal pain after consuming sweet and sour chicken from a Chinese restaurant.
• 😟 The initial pain was mild but worsened overnight, leading to a restless night and early bed rest.
• 🤢 The patient reported additional symptoms, including vomiting and diarrhea, which were lighter than normal.
• 🔍 The patient has no significant history with fried foods, but family history includes gallbladder problems.
• 🩺 The doctor inquired about the pain's location and intensity, discovering it primarily remained central with slight movement.
• 💧 Signs of dehydration were noted during the physical examination, prompting IV fluid administration.
• 🧪 Several tests were ordered to investigate the cause of the patient's symptoms, including CBC, EKG, and chest X-ray.
• 💊 The patient was prescribed anti-nausea medication (Zofran) and advised to stay hydrated.
• 🚑 A diagnosis of biliary colic was suggested after testing, highlighting the need for surgical consultation.
• 📅 The patient received discharge instructions, emphasizing the importance of follow-up and return if symptoms worsen.

Q & A

What initial symptom did the patient experience after eating Chinese food?

The patient experienced belly pain after eating sweet and sour chicken.

How did the patient's belly pain progress over time?

The belly pain started as mild discomfort but worsened throughout the night, leading the patient to go to bed early due to increased pain.

What additional symptoms did the patient report aside from belly pain?

The patient reported vomiting and diarrhea, with the stool being lighter than normal.

Did the patient have any prior history of similar symptoms?

Yes, the patient mentioned having severe belly issues in childhood but had no problems with fried foods in the past.

What family history was relevant to the patient's condition?

The patient noted a family history of gallbladder problems, mentioning that their mother had gallbladder attacks.

What examinations did the doctor perform during the consultation?

The doctor conducted a physical examination, focusing on the location and nature of the pain.

What tests did the doctor order to evaluate the patient's condition?

The doctor ordered a CBC, basic metabolic panel, liver function tests, urinalysis, EKG, chest x-ray, and troponin levels.

What treatment did the patient receive while at the medical facility?

The patient received IV fluids for dehydration and anti-nausea medication (Zofran) to alleviate symptoms.

What was the diagnosis made by the doctor?

The doctor diagnosed the patient with biliary colic.

What instructions did the doctor provide upon discharge?

The doctor instructed the patient to follow up with an on-call surgeon if symptoms worsened.