🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-06-19 07:10:32

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.
[00:21 → 00:30] Like walking fast, climbing stairs, or carrying groceries. Dr. Mera, I see, can you describe
[00:30 → 00:37] this discomfort? Is it sharp? Burning? Pressure like? Mr. Sharma, it feels more like pressure.
[00:38 → 00:44] Like a weight on my chest, it usually lasts a few minutes and goes away when I sit or slow down.
[00:45 → 00:50] Dr. Mera, have you noticed any accompanying symptoms? Shortness of breath,
[00:50 → 00:59] lightheadedness, sweating, or pain radiating to your arm or jaw? Mr. Sharma, yes, I do feel a little
[00:59 → 01:06] breathless, especially if I push myself. No pain in the arms or jaw, though, and I've had
[01:06 → 01:13] a few episodes where I felt a bit dizzy afterward. Dr. Mera, all right, thank you for sharing
[01:14 → 01:20] that. Let's take a look at your vitals. First, your blood pressure today is 142 over 88.
[01:21 → 01:28] Slightly elevated. Your pulse is regular at 82 beats per minute. And your oxygen saturation
[01:28 → 01:36] is 97%. Any changes in your medication or diet recently? Mr. Sharma, I've been trying to reduce
[01:36 → 01:44] salt and walk 30 minutes daily. But I do sometimes forget my evening dose of amlota peen. Dr. Mera,
[01:44 → 01:49] that could be contributing to the elevated blood pressure. And what about your diabetes?
[01:50 → 01:57] Were you monitoring your glucose levels? Mr. Sharma, yes, I check it every morning. It's usually
[01:57 → 02:06] around 110 to 120. I haven't started medication yet. Dr. Mera, that's manageable for now,
[02:06 → 02:12] 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 in 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
[02:41 → 02:49] to 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 → 03:04] Mr. Sharma, that sounds like a lot. Will there be any side effects I should watch out for? Dr.
[03:04 → 03:10] Mera, that's a fair concern. You might experience mild fatigue or muscle aches with the statin,
[03:10 → 03:17] but most people tolerate it well. The aspirin can occasionally cause gastritis. So I'll prescribe a
[03:17 → 03:23] gastroprotective medicine along with it. Let me know if you experience any black stools.
[03:24 → 03:32] Stomach pain or unusual bruising. Mr. Sharma, understood. Should I avoid any particular foods?
[03:32 → 03:41] Dr. Mera, yes. Continue your low sodium diet. Reduce saturated fats and increase intake of vegetables.
[03:42 → 03:47] 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 → 04:16] My team will call you to book the diagnostic appointments. In the meantime, if you experience severe
[04:16 → 04:24] chest pain, shortness of breath or feel faint, please go to the emergency room immediately. Mr. Sharma,
[04:24 → 04:33] thank you. Dr. This was very helpful. Dr. Mera, you're welcome. Mr. Sharma, we'll stay proactive and
[04:33 → 04:39] make sure everything is under control. I'll have the nurse explain the prescriptions and testing
[04:39 → 04:40] 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 sensation as pressure that lasts a few minutes and resolves when sitting or slowing down. Reports feeling breathless and dizzy on exertion.

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

  • Diet and Exercise: Trying to reduce salt intake, walking for 30 minutes daily.

  • Glucose Monitoring: Checks glucose levels every morning, ranging from 110 to 120, not on medication for diabetes yet.

Objective

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

Assessment

  1. Cardiac Concerns:
  2. Chest discomfort on exertion, associated with breathlessness and dizziness.
  3. Elevated blood pressure.

  4. Need for further cardiac evaluation with ECG, echocardiogram, and treadmill stress test.

  5. Hypertension:

  6. Suboptimal blood pressure control, possibly due to missed evening dose of amlodipine.

  7. Diabetes Management:

  8. Glucose levels within range, not on medication yet, requires monitoring.

Plan

  1. Diagnostic Tests:

  2. Schedule ECG, echocardiogram, and treadmill stress test within the next week to assess cardiac function.

  3. Medication Adjustments:

  4. Increase amlodipine dose to 10 mg once daily.
  5. Initiate low-dose aspirin (81 mg/day) for antiplatelet effect.

  6. Prescribe a statin to lower LDL cholesterol levels.

  7. Monitoring and Education:

  8. Educate on potential side effects of medications (fatigue, muscle aches with statin; gastritis with aspirin).
  9. Prescribe gastroprotective medication to mitigate aspirin-related gastritis.
  10. Advise on dietary modifications: low sodium, reduced saturated fats, increased vegetables, legumes, lean protein. Avoid smoking, limit alcohol intake.

  11. Emphasize hydration, consistent physical activity, and avoiding overexertion until stress test completion.

  12. Follow-Up:

  13. Schedule a follow-up appointment in two weeks to review test results.
  14. Nurse to provide information on prescriptions and testing schedule before the patient leaves.
⬅ Back to History