🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-09-04 05:59:20
Transcript
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<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, doctor. I've been alright 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? Lightheadedness? 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>: Alright, 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 amlodipine.</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 an 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 amlodipine dose to 10mg once daily and start you on a low-dose aspirin. 81mg 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. 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, doctor. This was very helpful.</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="Doctor">Doctor</strong>: You're welcome.</p></div></td></tr><tr><td id="fragmentid_22"><div><p><strong class="Patient">Patient</strong>: 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
Allergies
No significant allergy history.
Chief Complaints / HOPI / Examination
- Chest discomfort on exertion
- Pressure-like sensation in the chest
- Shortness of breath on exertion
- Occasional dizziness
- Blood pressure: 142/88 mmHg
- Pulse: 82 beats per minute
- Oxygen saturation: 97%
Provisional Diagnosis/Diagnosis:
- Angina pectoris
Investigations / Medication Advised
Laboratory:
- None specified
Radiology:
- ECG
- Echocardiogram
- Treadmill stress test
Medication
|-----|-----------|-------|------|-----------|----------|---------| | Sr. | Drug Name | Route | Dose | Frequency | Duration | Remarks | | 1 | Amlodipine | Oral | 10mg | OD (once daily) | - | - | | 2 | Aspirin | Oral | 81mg | OD (once daily) | - | - | | 3 | Statin | Oral | - | - | - | Monitor for muscle aches | | 4 | Gastroprotective agent | Oral | - | - | - | To prevent gastritis from aspirin |
Advice / Follow-Up
- Continue low-sodium diet
- Reduce saturated fats
- Increase intake of vegetables, legumes, and lean protein
- Avoid smoking and limit alcohol
- Maintain hydration and consistent physical activity, preferably brisk walking
- Avoid overexertion until stress test is completed
- Follow-up in two weeks after test results
- Seek immediate medical attention if experiencing severe chest pain, shortness of breath, or feeling faint