🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-08 04:31:39

Transcript

[00:00 → 00:06] Good afternoon Mr. Patel, I see you are here for a follow up on your cholesterol and
[00:06 → 00:08] fat pressure readings.
[00:08 → 00:09] How have things been?
[00:09 → 00:15] Good afternoon Dr. I have been trying to offer regularly and eat healthier.
[00:15 → 00:18] I have also cut down on red meat and salt as you suggested.
[00:18 → 00:19] That's excellent.
[00:19 → 00:26] Here a further showing your blood pressure has come down to 128.082 and your LDL cholesterol
[00:26 → 00:27] top by 12%.
[00:27 → 00:33] It will still experience shortness of breath only a little when I take steers too quickly
[00:33 → 00:35] but much better than before.
[00:35 → 00:36] Good to hear.
[00:36 → 00:42] We will continue with your current statin and add a beta brothel to support heart function.
[00:42 → 00:48] Also, considering your family history, I would like to schedule a city conography endogram.
[00:48 → 00:52] Okay, if you think it's necessary, it's a preventive step.
[00:52 → 00:55] We will review the result together in two weeks.
[00:55 → 00:58] My meanwhile, stay consistent with your diet, medication and exercise.

Clinical Notes

Subjective

  • Patient: Mr. Patel.

  • Primary Concern: Follow-up on cholesterol and blood pressure readings.

    • Reports efforts to eat healthier, exercise regularly, and following advice to cut down on red meat and salt.

    • Mentions experiencing improved symptoms with reduced shortness of breath.

Objective

  • Medical History:

    • Blood pressure: 128/82 mmHg.

    • LDL cholesterol reduced by 12%.

  • Symptoms:

    • Improved shortness of breath with fast movements.

Assessment

  1. Cardiovascular Health:

    • Improved blood pressure and LDL cholesterol levels.

    • Persistent mild shortness of breath with rapid movements.

  2. Medication:

    • Continuing current statin and adding a beta-blocker for heart support.

  3. Preventive Care:

    • Considering family history, scheduling a CT angiography and echocardiogram.

Plan

  1. Treatment:

    • Continue current statin medication.

    • Initiate beta-blocker for heart function support.

  2. Diagnostic Tests:

    • Schedule CT angiography and echocardiogram to assess cardiovascular health.

  3. Follow-Up:

    • Review test results together in two weeks.

    • Emphasize consistency with diet, medication, and exercise regimen.

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