🩺 Record Detail
Patient Info
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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="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><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 Identifying Information: - Patient Name: Mr. Sharma
Chief Complaint: - Experiencing discomfort in the chest when exerting himself, such as walking fast, climbing stairs, or carrying groceries.
History of Presenting Illness: - Mr. Sharma reports feeling pressure on his chest when exerting himself, lasting a few minutes and resolving when he rests. - He experiences breathlessness with exertion and occasional dizziness post-exertion.
Symptoms: - Chest discomfort - Breathlessness - Dizziness
Past Medical History: - Hypertension - Diabetes
Medications: - Evening dose of amlodipine occasionally forgotten
Objective: - Blood pressure: 142/88 mmHg - Pulse: 82 bpm - Oxygen saturation: 97%
Assessment: - Elevated blood pressure likely influenced by missed evening dose of amlodipine. - Diabetes currently managed with morning glucose levels around 110-120. - Symptoms suggestive of cardiac origin necessitate further evaluation with ECG, echocardiogram, and treadmill stress test.
Plan: - Schedule ECG, echocardiogram, and treadmill stress test within the next week to assess cardiac function under physical exertion. - Emphasize adherence to medication regimen for hypertension. - Monitor glucose levels closely and consider medication initiation if needed.