🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-31 13:36:20

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong>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>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>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>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>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>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>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>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>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="SPEAKER-01">SPEAKER-01:</strong> episodes where I felt a bit dizzy afterward. Dr. Mera, all right,</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Let's take a look at your vitals. First, your blood pressure today is 142</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Slightly elevated. Your pulse is regular at 82 beats per minute. And your oxygen</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> 97%. Any changes in your medication or diet recently? Mr. Sharma,</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> 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_15"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> that could be contributing to the elevated blood pressure. And what about your</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Were you monitoring your glucose levels? Mr. Sharma, yes, I check it</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><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: but we need to keep an eye on it. Coming back to the chest discomfort. Based on your symptoms,</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

Subjective

  • Patient: Mr. Sharma.

  • Primary Concern: Experiencing chest discomfort when exerting himself, such as walking fast, climbing stairs, or carrying groceries. Describes the sensation as pressure on the chest, lasting a few minutes and relieved by rest.

  • Associated Symptoms: Reports feeling breathless, especially with exertion, occasional dizziness post-exertion.

  • Medication Adherence: Occasionally forgets the evening dose of amlodipine.

  • Glucose Monitoring: Monitors glucose levels, averaging around 110 to 120, not on medication yet.

Objective

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

Assessment

  1. Chest Discomfort: Experiences pressure-like chest discomfort with exertion, associated with breathlessness and occasional dizziness post-exertion.

  2. Hypertension: Elevated blood pressure readings, possibly influenced by inconsistent amlodipine adherence.

  3. Glucose Monitoring: Glucose levels averaging around 110 to 120, requiring continued monitoring.

Plan

  1. Diagnostic Tests:
  2. Order an ECG and an echocardiogram to assess heart function during physical exertion.
  3. Schedule tests within the next week.

  4. Medication Management:

  5. Emphasize the importance of consistent amlodipine adherence for blood pressure control.

  6. Glucose Monitoring:

  7. Continue monitoring glucose levels closely.
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