🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-07 06:48:57

Transcript

[00:00 → 00:06] Dr. Mera, good morning, Mr. Sharma. It's good to see you again. How have you been since our
[00:06 → 00:14] last appointment in January? Mr. Sharma, good morning, Dr. I've been all right for the most part.
[00:14 → 00:21] But over the last month, I've started experiencing some discomfort in my chest when I exert myself.
[00:21 → 00:30] Like walking fast, climbing stairs, or carrying groceries. Dr. Mera, I see, can you describe
[00:30 → 00:37] this discomfort? Is it sharp? Burning? Pressure like? Mr. Sharma, it feels more like pressure.
[00:38 → 00:44] Like a weight on my chest, it usually lasts a few minutes and goes away when I sit or slow down.
[00:45 → 00:50] Dr. Mera, have you noticed any accompanying symptoms? Shortness of breath,
[00:50 → 00:59] lightheadedness, sweating, or pain radiating to your arm or jaw? Mr. Sharma, yes, I do feel a little
[00:59 → 01:06] breathless, especially if I push myself. No pain in the arms or jaw, though, and I've had
[01:06 → 01:13] a few episodes where I felt a bit dizzy afterward. Dr. Mera, all right, thank you for sharing
[01:14 → 01:20] that. Let's take a look at your vitals. First, your blood pressure today is 142 over 88.
[01:21 → 01:28] Slightly elevated. Your pulse is regular at 82 beats per minute. And your oxygen saturation
[01:28 → 01:36] is 97%. Any changes in your medication or diet recently? Mr. Sharma, I've been trying to reduce
[01:36 → 01:44] salt and walk 30 minutes daily. But I do sometimes forget my evening dose of amlota peen. Dr. Mera,
[01:44 → 01:49] that could be contributing to the elevated blood pressure. And what about your diabetes?
[01:50 → 01:57] Were you monitoring your glucose levels? Mr. Sharma, yes, I check it every morning. It's usually
[01:57 → 02:06] around 110 to 120. I haven't started medication yet. Dr. Mera, that's manageable for now,
[02:06 → 02:12] but we need to keep an eye on it. Coming back to the chest discomfort. Based on your symptoms,
[02:12 → 02:20] I'd like to run a few tests, specifically in ECG, an echocardiogram, and a treadmill stress test
[02:20 → 02:28] these will help us assess how your heart responds under physical. Exertion. Mr. Sharma, okay,
[02:28 → 02:35] do I need to get them done today? Dr. Mera, we'll schedule them within the next week. In the meantime,
[02:35 → 02:41] I'm going to make a few adjustments to your treatment plan. I'll increase your amlota peen dose
[02:41 → 02:49] to 10 milligrams once daily and start you on a low dose aspirin. 81 milligrams per day. To reduce
[02:49 → 02:56] the risk of any clot formation, I'll also prescribe a statin to help lower your LDL cholesterol.
[02:57 → 03:04] Mr. Sharma, that sounds like a lot. Will there be any side effects I should watch out for? Dr.
[03:04 → 03:10] Mera, that's a fair concern. You might experience mild fatigue or muscle aches with the statin,
[03:10 → 03:17] but most people tolerate it well. The aspirin can occasionally cause gastritis. So I'll prescribe a
[03:17 → 03:23] gastroprotective medicine along with it. Let me know if you experience any black stools.
[03:24 → 03:32] Stomach pain or unusual bruising. Mr. Sharma, understood. Should I avoid any particular foods?
[03:32 → 03:41] Dr. Mera, yes. Continue your low sodium diet. Reduce saturated fats and increase intake of vegetables.
[03:42 → 03:47] Legumes and lean protein. Avoid smoking and limit alcohol.
[03:47 → 03:54] Hydration and consistent physical activity are important too. Preferably brisk walking,
[03:54 → 04:01] but don't overexert yourself until we complete the stress test. Mr. Sharma, I'll try my best.
[04:01 → 04:08] Dr. What about follow ups? Dr. Mera, we'll see you again in two weeks once the test results are in.
[04:09 → 04:16] My team will call you to book the diagnostic appointments. In the meantime, if you experience severe
[04:16 → 04:24] chest pain, shortness of breath or feel faint, please go to the emergency room immediately. Mr. Sharma,
[04:24 → 04:33] thank you. Dr. This was very helpful. Dr. Mera, you're welcome. Mr. Sharma, we'll stay proactive and
[04:33 → 04:39] make sure everything is under control. I'll have the nurse explain the prescriptions and testing
[04:39 → 04:40] schedule before you leave.

Clinical Notes

Subjective

  • Patient: Mr. Sharma

  • Chief Complaint: Experiencing discomfort in the chest when exerting himself, such as walking fast, climbing stairs, or carrying groceries. Describes the discomfort as pressure that lasts a few minutes and is relieved by sitting or slowing down. Reports feeling breathless and dizzy during exertion.

  • Medication History: Occasionally forgets the evening dose of amlodipine.

  • Diabetes: Monitors glucose levels daily, ranging from 110 to 120 in the morning. Has not started medication yet.

Objective

  • Vitals:
  • Blood pressure: 142/88 mmHg (slightly elevated)
  • Pulse: 82 bpm
  • Oxygen saturation: 97%

Assessment

  1. Hypertension: Elevated blood pressure, possibly due to missed evening dose of amlodipine.

  2. Diabetes: Glucose levels within manageable range, requires monitoring.

  3. Cardiovascular Risk Assessment: Chest discomfort with exertion warrants further evaluation with ECG, echocardiogram, and treadmill stress test to assess heart response under physical exertion.

Plan

  1. Diagnostic Tests:

  2. Schedule ECG, echocardiogram, and treadmill stress test within the next week.

  3. Medication Adjustments:

  4. Increase amlodipine dose to 10mg once daily.
  5. Initiate low-dose aspirin (81mg/day) to reduce clot formation risk.

  6. Prescribe a statin to lower LDL cholesterol levels.

  7. Monitoring:

  8. Advise to watch for side effects such as fatigue, muscle aches with statin, and potential gastritis with aspirin. Prescribe gastroprotective medication.

  9. Instruct to report any black stools, stomach pain, or unusual bruising.

  10. Lifestyle Modifications:

  11. Continue low sodium diet, reduce saturated fats, and increase intake of vegetables, legumes, and lean protein.

  12. Encourage avoidance of smoking, limiting alcohol intake, maintaining hydration, and consistent physical activity.

  13. Follow-Up:

  14. Schedule a follow-up appointment in two weeks to review test results.
  15. Nurse to provide explanations regarding prescriptions and testing schedule before the patient leaves.
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