🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-05 08:07:39

Transcript

<thead>
                                                <tr>
                                                   <th><strong>Original Transcription</strong></th>
                                                </tr>
                                             </thead>
                                             <tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">Doctor</strong>: Good morning, Mr. Sharma. It's good to see you again. How have you been since our last appointment in January?</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="Patient">Patient</strong>: Good morning, Dr. I've been all right for the most part. But over the last month, I've started experiencing some discomfort in my chest when I exert myself. Like walking fast, climbing stairs, or carrying groceries.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="Doctor">Doctor</strong>: I see, can you describe this discomfort? Is it sharp? Burning. Pressure like?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="Patient">Patient</strong>: It feels more like pressure. Like a weight on my chest, it usually lasts a few minutes and goes away when I sit or slow down.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="Doctor">Doctor</strong>: Have you noticed any accompanying symptoms? Shortness of breath, light-headedness, sweating, or pain radiating to your arm or jaw?</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="Patient">Patient</strong>: Yes, I do feel a little breathless, especially if I push myself. No pain in the arms or jaw, though, and I've had a few episodes where I felt a bit dizzy afterward.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="Doctor">Doctor</strong>: All right, thank you for sharing that. Let's take a look at your vitals. First, your blood pressure today is 142 over 88. Slightly elevated. Your pulse is regular at 82 beats per minute. And your oxygen saturation is 97%. Any changes in your medication or diet recently?</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="Patient">Patient</strong>: I've been trying to reduce salt and walk 30 minutes daily. But I do sometimes forget my evening dose of amlota peen.</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="Doctor">Doctor</strong>: That could be contributing to the elevated blood pressure. And what about your diabetes? Were you monitoring your glucose levels?</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="Patient">Patient</strong>: Yes, I check it every morning. It's usually around 110 to 120. I haven't started medication yet.</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="Doctor">Doctor</strong>: That's manageable for now, but we need to keep an eye on it. Coming back to the chest discomfort. Based on your symptoms, I'd like to run a few tests, specifically in ECG, an echocardiogram, and a treadmill stress test these will help us assess how your heart responds under physical exertion.</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="Patient">Patient</strong>: Okay, do I need to get them done today?</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="Doctor">Doctor</strong>: We'll schedule them within the next week. In the meantime, I'm going to make a few adjustments to your treatment plan. I'll increase your amlota peen dose to 10 milligrams once daily and start you on a low dose aspirin. 81 milligrams per day. To reduce the risk of any clot formation, I'll also prescribe a statin to help lower your LDL cholesterol.</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="Patient">Patient</strong>: That sounds like a lot. Will there be any side effects I should watch out for?</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="Doctor">Doctor</strong>: That's a fair concern. You might experience mild fatigue or muscle aches with the statin, but most people tolerate it well. The aspirin can occasionally cause gastritis. So I'll prescribe a gastroprotective medicine along with it. Let me know if you experience any black stools. Stomach pain or unusual bruising.</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="Patient">Patient</strong>: Understood. Should I avoid any particular foods?</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="Doctor">Doctor</strong>: Yes, continue your low sodium diet. Reduce saturated fats and increase intake of vegetables. Legumes and lean protein. Avoid smoking and limit alcohol. Hydration and consistent physical activity are important too. Preferably brisk walking, but don't overexert yourself until we complete the stress test.</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="Patient">Patient</strong>: I'll try my best. Dr. What about follow ups?</p></div></td></tr><tr><td id="fragmentid_19"><div><p><strong class="Doctor">Doctor</strong>: We'll see you again in two weeks once the test results are in. My team will call you to book the diagnostic appointments. In the meantime, if you experience severe chest pain, shortness of breath, or feel faint, please go to the emergency room immediately.</p></div></td></tr><tr><td id="fragmentid_20"><div><p><strong class="Patient">Patient</strong>: Thank you. Dr. this was very helpful.</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="Doctor">Doctor</strong>: You're welcome. Mr. Sharma, we'll stay proactive and make sure everything is under control. I'll have the nurse explain the prescriptions and testing schedule before you leave.</p></div></td></tr></tbody>

Clinical Notes

Subjective:

The patient reports experiencing discomfort in the chest when exerting himself, such as walking fast, climbing stairs, or carrying groceries. He describes the sensation as pressure, feeling like a weight on his chest, lasting a few minutes and subsiding when he sits or slows down. He also mentions feeling breathless, especially with exertion, occasional dizziness, but denies pain in the arms or jaw.

The patient admits to forgetting the evening dose of amlodipine and mentions efforts to reduce salt intake and engage in daily walks. He checks his glucose levels in the morning, ranging from 110 to 120, without starting medication for diabetes.

Objective:

  • Blood pressure: 142/88 mmHg
  • Pulse: 82 bpm
  • Oxygen saturation: 97%

Assessment:

  1. Chest discomfort on exertion, suggestive of angina.
  2. Elevated blood pressure with suboptimal control.
  3. Diabetes with morning glucose levels around 110-120.
  4. Risk factors for cardiovascular disease.

Plan:

  1. Investigations:
  2. ECG
  3. Echocardiogram
  4. Treadmill stress test

  5. Medications:

  6. Increase amlodipine dose to 10mg once daily
  7. Start low-dose aspirin (81mg/day)
  8. Prescribe a statin for LDL cholesterol reduction

  9. Instructions:

  10. Continue low sodium diet
  11. Reduce saturated fats, increase vegetables, legumes, and lean protein intake
  12. Avoid smoking, limit alcohol consumption
  13. Hydration and consistent physical activity, preferably brisk walking
  14. Await diagnostic appointments for further management

  15. Follow-up:

  16. Follow-up in two weeks after test results
  17. Emergency room visit advised for severe chest pain, shortness of breath, or faintness.
⬅ Back to History