🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-08 08:58:41

Transcript

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                                                   <th><strong>Original Transcription</strong></th>
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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. 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, doctor. 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


Clinical Notes

Doctor: DOCTOR_NAME

Patient: Mr. Sharma

Date: SESSION_DATE

Subjective: - Chief Complaint: Chest discomfort during exertion. - History of Present Illness: Mr. Sharma reports experiencing pressure-like chest discomfort over the last month, particularly during activities such as walking fast, climbing stairs, or carrying groceries. The discomfort lasts a few minutes and subsides with rest. He also notes shortness of breath and occasional dizziness post-exertion, but no pain radiating to the arms or jaw. - Past Medical History: Hypertension, Diabetes (not on medication yet). - Current Medications: Amlodipine (occasionally missed evening dose). - Lifestyle: Attempting to reduce salt intake and walks 30 minutes daily.

Objective: - Vital Signs: Blood pressure 142/88 mmHg, Pulse 82 bpm, Oxygen saturation 97%. - Physical Examination: Not detailed in the transcript.

Assessment: - Elevated blood pressure, possibly due to missed doses of amlodipine. - Chest discomfort with exertion, suspecting cardiac origin. - Diabetes under monitoring with glucose levels between 110-120 mg/dL.

Plan: 1. Diagnostics: - Schedule ECG, echocardiogram, and treadmill stress test within the next week.

  1. Medications:
  2. Increase Amlodipine to 10mg once daily.
  3. Start low-dose aspirin 81mg per day.
  4. Prescribe a statin to lower LDL cholesterol.
  5. Prescribe a gastroprotective agent to accompany aspirin to prevent gastritis.

  6. Lifestyle Modifications:

  7. Continue low-sodium diet.
  8. Reduce saturated fats; increase vegetables, legumes, and lean protein.
  9. Avoid smoking and limit alcohol intake.
  10. Maintain hydration and consistent physical activity, preferably brisk walking without overexertion.

  11. Follow-Up:

  12. Schedule follow-up in two weeks after test results are available.
  13. Instruct patient to seek emergency care if experiencing severe chest pain, shortness of breath, or fainting.

Instructions: - The nurse will explain prescriptions and testing schedule before the patient leaves. - Monitor for side effects such as fatigue or muscle aches from statin, and gastritis symptoms from aspirin.

Notes: - The patient should be vigilant about medication adherence and lifestyle changes to manage symptoms and prevent complications.


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