🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-24 10:53:09

Transcript

<p><strong>Doctor</strong>: Good morning, Anita. How are you feeling today?&nbsp;</p><p><strong>Patient</strong>: Good morning, Doctor. I'm feeling better than last month, but I still get a bit tired after climbing stairs.</p><p><strong>Doctor</strong>: I see. That's actually helpful to know. Let's go over a few things. How's the chest discomfort? Any pain or tightness recently?</p><p><strong>Patient</strong>: No pain as such, but sometimes I do feel a little pressure when I walk briskly, especially in the cold.</p><p><strong>Doctor</strong>: That could be related to exertion. Are you taking your medications regularly?</p><p><strong>Patient</strong>: Yes, I've been very careful with that. I take the blood pressure pills every morning and the cholesterol medication after dinner, just like you told me.</p><p><strong>Doctor</strong>: Excellent. Your blood pressure readings from your last visit were much improved, and your ECG looks stable. I'm glad to hear you're staying consistent. Have you made any changes to your diet or physical activity?</p><p><strong>Patient</strong>: I've started eating less fried food, and I've been walking 20 minutes every evening after dinner.</p><p><strong>Doctor</strong>: That's a great start. Try to increase your walking to 30 minutes if you can, at least five times a week. And keep an eye on how you feel during those walks, if you feel shortness of breath or chest pressure, slow down and let me know.</p><p><strong>Patient</strong>: Got it. Should I still avoid stairs for now?</p><p><strong>Doctor</strong>: You don't have to avoid them completely, but don't push yourself. Take breaks if you feel winded, and use the handrail. We'll reassess in a few weeks.</p><p><strong>Patient</strong>: Alright. Do I need another test or scan soon?</p><p><strong>Doctor</strong>: Not immediately. I'll order a stress test for next month, just to check how your heart is responding to physical activity. In the meantime, continue the medication, walk regularly, and stick to the heart healthy diet.</p><p><strong>Patient</strong>: Thank you, doctor. I feel more confident now.</p><p><strong>Doctor</strong>: That's good to hear, Anita. You're doing well, just take it one step at a time. I'll see you in four weeks, and feel free to call if anything unusual comes up.</p><p><strong>Patient</strong>: We'll do. Thanks again.</p><p><strong>Doctor</strong>: Take care, Anita.</p>

Clinical Notes

Subjective

  • Patient: Anita.

  • Primary Concern: Feeling better than last month but gets tired after climbing stairs. Reports feeling pressure when walking briskly, especially in the cold.

  • Medication Adherence:

    • Takes blood pressure pills every morning and cholesterol medication after dinner as prescribed.
  • Lifestyle Changes:

    • Started eating less fried food.

    • Walks for 20 minutes every evening after dinner.

Objective

  • Medical History:

    • Blood pressure readings from the last visit improved.

    • Stable ECG.

Assessment

  1. Cardiovascular Health:

    • Patient reports feeling pressure during brisk walking, especially in the cold.
  2. Medication Adherence:

    • Compliant with blood pressure and cholesterol medications.
  3. Lifestyle Modifications:

    • Improved diet by reducing fried food intake.

    • Started regular walking routine.

Plan

  1. Monitoring:

    • Order a stress test for next month to assess heart response to physical activity.
  2. Lifestyle Recommendations:

    • Increase walking duration to 30 minutes at least five times a week.

    • Advise to monitor for shortness of breath or chest pressure during walks.

    • Encourage to continue heart-healthy diet.

  3. Activity Modification:

    • Patient advised not to push herself on stairs, take breaks if feeling winded, and use handrails.
  4. Follow-Up:

    • Schedule a follow-up appointment in four weeks.

    • Instructed to contact the doctor if any unusual symptoms arise.

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