🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-04 04:45:27

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, 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 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 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="SPEAKER-01">SPEAKER-01:</strong> around 110 to 120. I haven't started medication yet. Dr. Mera, that's</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> but we need to keep an eye on it. Coming back to the chest discomfort. Based on</p></div></td></tr><tr><td id="fragmentid_19"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I'd like to run a few tests, specifically in ECG, an echocardiogram, and a</p></div></td></tr><tr><td id="fragmentid_20"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> these will help us assess how your heart responds under physical. Exertion. Mr.</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> do I need to get them done today? Dr. Mera, we'll schedule them within the next week.</p></div></td></tr></tbody>

Clinical Notes

Patient Information - Patient Name: Mr. Sharma - Date of Birth: N/A - Date of Visit: N/A - Gender: Male - Patient ID: N/A


Chief Complaint (CC): "Patient reports experiencing discomfort in the chest when exerting himself."


History of Present Illness (HPI): - Onset: Last month - Duration: Lasts a few minutes - Location: Chest - Quality: Pressure - Associated Symptoms: Shortness of breath, dizziness - Aggravating/Relieving Factors: Exertion worsens, sitting or slowing down relieves - Medications tried: Amlodipine


Past Medical History (PMH): - Hypertension - Diabetes


Social History: - Medications: Amlodipine - Lifestyle: Trying to reduce salt intake, walking 30 minutes daily


Physical Examination (PE): - Blood Pressure: 142/88 mmHg - Pulse: 82 bpm - Oxygen Saturation: 97% - General Appearance: N/A


Assessment: - Primary Diagnosis: Chest discomfort on exertion, likely cardiac origin - Secondary Diagnosis: Hypertension, Diabetes


Plan: - Investigations: ECG, echocardiogram, treadmill stress test - Medications Prescribed: Increase Amlodipine to 10mg daily, start low-dose aspirin (81mg/day), prescribe statin for LDL cholesterol - Monitoring: Glucose levels, blood pressure - Lifestyle: Continue salt reduction, daily walking - Education: Watch for side effects of new medications - Follow-Up: Schedule tests within the next week

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