🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-06 07:38:35

Transcript

[00:30 → 00:41] Good morning, Mrs. Sharma. Good to see you again. How have you been? Since I last
[00:41 → 00:49] upon your reach, I have been all right far, most part, with all of us. I have started
[00:49 → 00:55] doing some disco 40 matches. When I started myself, I was walking fast,
[00:55 → 01:03] climbing steers, or carrying a crossways. I see, can you describe the disco 40? Is it sharp,
[01:03 → 01:10] burning, pressure-like? It feels more like pressure, like a weight on my chest. It usually
[01:10 → 01:17] lasts a few minutes and goes away when I sit also. Have you noticed any accompanying symptoms,
[01:17 → 01:26] shortness of breath, light, hoodedness, sweating, or pain radiating to your arm or jaw? Yes, I do
[01:26 → 01:33] feel the little breathless, especially if I push myself. No pain in arm or jaw, though, and I have
[01:33 → 01:41] a few episodes where I have felt a bit dizzy after all. All right, thank you for sharing that. Let's
[01:41 → 01:48] take a look at your vital force. Your breath pressure today is 142 over 88. Slightly elevated. Your
[01:48 → 01:55] pulse is regular at 32 minutes per minute, and your oxygen saturation is 97. Any changes in your
[01:55 → 02:01] medication are tied to something. I have been trying to reduce salt and walk 30 minutes
[02:02 → 02:11] but I do something for good in my evening. Those of am low-depying that would be contributing to the
[02:11 → 02:17] elevated blood pressure, and what about your diabetes? Were you monitoring your glucose levels?
[02:18 → 02:24] Yes, I check it every morning. It usually around 110 to 120. I haven't started medication yet.
[02:26 → 02:31] That's manageable for now, but we need to keep an eye on it, coming back to the disco 40.
[02:32 → 02:37] Based on your symptoms, I would like to learn a few tests, especially specifically in ECG and
[02:37 → 02:44] eco-cardiogram and a threadless wrist wrist. These will help us assess how your heart responds
[02:44 → 02:46] and the physical expression.

Clinical Notes

Subjective

  • Patient: Mrs. Sharma.

  • Primary Concern: Experiencing pressure-like sensation on the chest during physical activities, accompanied by breathlessness and dizziness.

  • Symptoms:

    • Pressure on the chest lasting a few minutes.
    • Breathlessness, especially with exertion.
    • Episodes of dizziness.

  • Medical History:

    • Monitoring glucose levels daily with readings around 110 to 120.
    • Trying to reduce salt intake and walking for 30 minutes daily.

Objective

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

Assessment

  1. Cardiovascular Issue: Suspected angina based on chest pressure, breathlessness, and dizziness during physical activity.

  2. Hypertension: Slightly elevated blood pressure readings.

  3. Diabetes: Glucose levels around 110 to 120, not on medication yet.

Plan

  1. Diagnostic Tests:

    • Order an ECG, echocardiogram, and stress test to assess heart function and response to physical exertion.

  2. Monitoring:

    • Continue monitoring blood pressure and glucose levels regularly.

  3. Lifestyle Modifications:

    • Encourage continued salt reduction and daily exercise.
    • Discuss dietary modifications to manage blood pressure and diabetes.

  4. Follow-Up:

    • Schedule a follow-up appointment to review test results and adjust management plan accordingly.
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