🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-08 11:54:21

Transcript

[00:00 → 00:06] Dr. Mera, good morning, Mr. Sharma. It's good to see you again. How have you been since our
[00:06 → 00:14] last appointment in January? Mr. Sharma, good morning, Dr. I've been all right for the most part.
[00:14 → 00:21] But over the last month, I've started experiencing some discomfort in my chest when I exert myself.
[00:22 → 00:28] Like walking fast, climbing stairs, or carrying groceries. Dr. Mera,
[00:28 → 00:36] I see. Can you describe this discomfort? Is it sharp, burning? Pressure like? Mr. Sharma,
[00:36 → 00:42] it feels more like pressure. Like a weight on my chest, it usually lasts a few minutes and goes
[00:42 → 00:48] away when I sit or slow down. Dr. Mera, have you noticed any accompanying symptoms?
[00:49 → 00:57] Shortness of breath, lightheadedness, sweating, or pain radiating to your arm or jaw. Mr. Sharma,
[00:57 → 01:05] yes, I do feel a little breathless, especially if I push myself. No pain in the arms or jaw,
[01:05 → 01:09] though, and I've had a few episodes where I felt a bit dizzy afterward.
[01:10 → 01:16] Dr. Mera, all right, thank you for sharing that. Let's take a look at your vitals first your
[01:16 → 01:26] blood pressure today is 142 over 88. Slightly elevated, your pulse is regular at 82 beats per minute,
[01:26 → 01:34] and your oxygen saturation is 97%. Any changes in your medication or diet recently. Mr. Sharma,
[01:34 → 01:41] I've been trying to reduce salt and walk 30 minutes daily, but I do sometimes forget my evening dose
[01:41 → 01:48] of amlota peen. Dr. Mera, that could be contributing to the elevated blood pressure. And what about your
[01:48 → 01:57] diabetes? Were you monitoring your glucose levels? Mr. Sharma, yes, I check it every morning.
[01:57 → 02:05] It's usually around 110 to 120. I haven't started medication yet. Dr. Mera, that's manageable for
[02:05 → 02:12] now, but we need to keep an eye on it. Coming back to the chest discomfort. Based on your symptoms,
[02:12 → 02:20] I'd like to run a few tests, specifically an ECG, an echocardiogram, and a treadmill stress test.
[02:20 → 02:28] These will help us assess how your heart responds under physical exertion. Mr. Sharma, okay,
[02:28 → 02:35] do I need to get them done today? Dr. Mera, we'll schedule them within the next week. In the meantime,
[02:35 → 02:41] I'm going to make a few adjustments to your treatment plan. I'll increase your amlota peen dose to
[02:41 → 02:49] 10 milligrams once daily and start you on a low dose aspirin. 81 milligrams per day. To reduce
[02:49 → 02:56] the risk of any clot formation, I'll also prescribe a statin to help lower your LDL cholesterol.
[02:57 → 03:03] Mr. Sharma, that sounds like a lot. Will there be any side effects I should watch out for?
[03:03 → 03:10] Dr. Mera, that's a fair concern. You might experience mild fatigue or muscle aches with the statin,
[03:10 → 03:16] but most people tolerate it well. The aspirin can occasionally cause gastritis.
[03:16 → 03:22] So I'll prescribe a gastroprotective medicine along with it. Let me know if you experience any
[03:22 → 03:31] black stools. Stomach pain or unusual bruising. Mr. Sharma, understood. Should I avoid any particular
[03:31 → 03:39] foods? Dr. Mera, yes. Continue your low sodium diet. Reduce saturated fats
[03:39 → 03:47] and increase intake of vegetables. Legumes and lean protein. Avoid smoking and limit alcohol.
[03:47 → 03:54] Hydration and consistent physical activity are important, too. Preferably brisk walking,
[03:54 → 04:01] but don't overexert yourself until we complete the stress test. Mr. Sharma, I'll try my best.
[04:01 → 04:08] Dr. What about follow ups? Dr. Mera, we'll see you again in two weeks once the test results are in.
[04:09 → 04:15] My team will call you to book the diagnostic appointments. In the meantime, if you experience
[04:15 → 04:22] severe chest pain, shortness of breath, or feel faint, please go to the emergency room immediately.
[04:23 → 04:32] Mr. Sharma, thank you. Dr. This was very helpful. Dr. Mera, you're welcome. Mr. Sharma,
[04:32 → 04:37] we'll stay proactive and make sure everything is under control. I'll have the nurse explain the
[04:37 → 04:46] prescriptions and testing schedule before you leave.

Clinical Notes

Subjective

  • Patient: Mr. Sharma.

  • Primary Concern: Experiencing discomfort in the chest when exerting himself, such as walking fast, climbing stairs, or carrying groceries. Describes the discomfort as pressure, lasting a few minutes, and relieved by rest. Reports feeling breathless and dizzy at times.

  • Medication/Diet History:

    • Trying to reduce salt intake and walking 30 minutes daily.
    • Forgetting evening dose of amlodipine.
    • Monitoring glucose levels every morning, ranging from 110 to 120, not on medication yet for diabetes.

Objective

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

Assessment

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

  2. Hypertension: Slightly elevated blood pressure, possibly influenced by missed evening dose of amlodipine.

  3. Diabetes: Glucose levels in the manageable range, monitoring required.

Plan

  1. Diagnostic Tests:

    • Schedule ECG, echocardiogram, and treadmill stress test to assess heart function under physical stress.

  2. Medication Adjustments:

    • Increase amlodipine dose to 10mg once daily.
    • Initiate low-dose aspirin (81mg/day) for clot prevention.
    • Prescribe a statin to lower LDL cholesterol.

  3. Monitoring:

    • Advise to watch for side effects like fatigue, muscle aches, or gastritis.
    • Instruct to report black stools, stomach pain, or unusual bruising.

  4. Lifestyle Modifications:

    • Continue low sodium diet, increase vegetable and lean protein intake, and reduce saturated fats.
    • Emphasize hydration, consistent physical activity, and brisk walking.
    • Encourage smoking cessation, limiting alcohol intake, and avoiding overexertion until stress test is completed.

  5. Follow-Up:

    • Schedule a follow-up appointment in two weeks to review test results.
    • Nurse to provide explanations on prescriptions and testing schedule before discharge.
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