🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-02 09:04:53

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong>Doctor</strong>: Good morning, Anita. How are you feeling today?</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong>Patient</strong>: Good morning, Dr. I'm feeling better than last month, but I still get a bit tired after climbing stairs.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong>Doctor</strong>: I see. That's actually helpful to know. Let's go over a few things. How's the chest discomfort? Any pain or tightness recently?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>Patient</strong>: No pain as such, but sometimes I do feel a little pressure when I walk briskly, especially in the cold.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong>Doctor</strong>: That could be related to exertion. Are you taking your medications regularly?</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong>Patient</strong>: Yes, I've been very careful with that. I take the blood pressure pills every morning and the cholesterol medication after dinner, just like you told me.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong>Doctor</strong>: Excellent. Your blood pressure readings from your last visit were much improved, and your ECG looks stable. I'm glad to hear you're staying consistent. Have you made any changes to your diet or physical activity?</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong>Patient</strong>: I've started eating less fried food, and I've been walking 20 minutes every evening after dinner.</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong>Doctor</strong>: That's a great start. Try to increase your walking to 30 minutes if you can, at least five times a week. And keep an eye on how you feel during those walks, if you feel shortness of breath or chest pressure, slow down and let me know.</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong>Patient</strong>: Got it. Should I still avoid stairs for now?</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong>Doctor</strong>: You don't have to avoid them completely, but don't push yourself. Take breaks if you feel winded, and use the handrail. We'll reassess in a few weeks.</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong>Patient</strong>: All right. Do I need another test or scan soon?</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong>Doctor</strong>: Not immediately. I'll order a stress test for next month, just to check how your heart is responding to physical activity. In the meantime, continue the medication, walk regularly, and stick to the heart healthy diet.</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong>Patient</strong>: Thank you, Dr. I feel more confident now.</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong>Doctor</strong>: That's good to hear. You're doing well, just take it one step at a time. I'll see you in four weeks, and feel free to call if anything unusual comes up.</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> feel winded, and use the handrail. We'll reassess in a few weeks. Anita, all</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> another test or scan soon? Dr. Amit, not immediately. I'll order a stress test for</p></div></td></tr></tbody>

Clinical Notes

Patient Information - Patient Name: Anita - Date of Birth: N/A - Date of Visit: N/A - Gender: Female - Patient ID: N/A


Chief Complaint (CC): Patient reports feeling better than last month but gets tired after climbing stairs.


History of Present Illness (HPI): - Onset: Last month - Duration: Persistent - Location: Generalized - Quality: Fatigue - Associated Symptoms: Tiredness after climbing stairs - Aggravating/Relieving Factors: Exertion - Medications tried: Blood pressure pills, cholesterol medication - Recent Travel / Sick Contacts / Exposure: N/A


Past Medical History (PMH): - Chronic Conditions: Hypertension, Hypercholesterolemia - Past Surgeries/Hospitalizations: N/A - Allergies: N/A - Current Medications: Blood pressure pills, cholesterol medication


Social History: - Smoking / Alcohol / Drug Use: N/A - Occupation: N/A - Living Situation: N/A


Review of Systems (ROS): - General: Fatigue - Cardiovascular: Chest discomfort with exertion - Respiratory: Shortness of breath on exertion


Physical Examination (PE): - Vital Signs: Stable - Cardiovascular: ECG stable - Respiratory: N/A


Assessment: - Primary Diagnosis: Hypertension, Hypercholesterolemia - Secondary Diagnosis: N/A


Plan: - Investigations: Stress test next month - Medications Prescribed: Continue blood pressure pills, cholesterol medication - Supportive Care: Encouraged to increase walking to 30 minutes, 5 times a week - Referral: N/A - Follow-Up: In four weeks

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