🩺 Record Detail
Patient Info
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, 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
Standardized Dietitian Consult Report
Patient Name: Mr. Sharma
Date of Visit: SESSION_DATE
Chief Complaint (CC): Chest discomfort during exertion, such as walking fast, climbing stairs, or carrying groceries.
Dietary History:
• Typical Diet:
• Breakfast: Not specified
• Lunch: Not specified
• Dinner: Not specified
• Snacks: Not specified
• Fruit and Vegetable Intake: Advised to increase intake.
• Processed Food Intake: Not specified
• Water Intake: Not specified
• Lactose Intolerance: Not reported
Medical History:
• Hypertension: Managed with amlodipine.
• Diabetes: Monitoring glucose levels, not on medication yet.
Medications:
• Amlodipine: Increased to 10mg once daily.
• Aspirin: 81mg per day.
• Statin: Prescribed to lower LDL cholesterol.
• Gastroprotective medicine: Prescribed to prevent gastritis from aspirin.
Allergies:
• None: Reports no known allergies.
Social History:
• Exercise: Engages in walking 30 minutes daily.
• Smoking: Advised to avoid smoking.
Family History:
• Not specified
Review of Systems (ROS):
• Cardiovascular: Chest pressure during exertion, slight breathlessness, episodes of dizziness.
• Constitutional: No significant changes reported.
Nutritional Assessment:
• BMI: [Insert BMI] (calculated based on weight and height provided).
• BMI Category: [Insert BMI category] (e.g., overweight, obese).
Body Composition Analysis: Not performed during this visit.
Dietary Intake Analysis: To be completed based on a food diary for the next few days.
Nutritional Requirements: Not specified in the provided transcript.
Nutrition Diagnosis:
• Inadequate Fruit and Vegetable Intake: Advised to increase intake.
• Possible Nutrient Deficiencies: Potential for deficiencies due to dietary habits.
Diet and Meal Planning:
• Recommendations: Continue low-sodium diet, reduce saturated fats, increase vegetables, legumes, and lean protein intake.
Nutritional Counseling:
• Recommendations: Provide guidance on meal planning, portion control, and healthy food choices.
Nutritional Education:
• Topics: Importance of balanced diet, hydration, and the role of fruits, vegetables, and whole grains in a healthy diet.
Specialized Diet Recommendations:
• Low-Sodium Diet: Continue with low-sodium dietary choices.
Weight Management Strategies:
• Recommendations: Encourage regular physical activity, preferably brisk walking, but avoid overexertion until stress test is completed.
Prognosis: Good with adherence to recommended dietary and lifestyle changes.
Follow-up Plan:
• Schedule: Follow-up appointment in two weeks to discuss test results and progress.
Patient Education:
• Topics: Importance of a healthy diet, hydration, and regular physical activity for overall health and well-being.
Consultation Recommendations:
• Food Diary Review: Review food diary upon completion to assess dietary intake and provide further personalized recommendations.
Referral Recommendations:
• None: No referrals indicated at this time.