🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-30 12:39:52

Transcript

[00:00 → 00:06] Doctor Amit, good morning, Anita. How are you feeling today? Anita, good morning,
[00:06 → 00:13] Doctor. I'm feeling better than last month, but I still get a bit tired after climbing stairs.
[00:13 → 00:20] Doctor Amit, I see. That's actually helpful to know. Let's go over a few things. How's the
[00:20 → 00:28] chest discomfort? Any pain or tightness recently? Anita, no pain as such, but sometimes I do feel
[00:28 → 00:34] a little pressure when I walk briskly, especially in the cold. Doctor Amit, that could be related to
[00:34 → 00:41] exertion. Are you taking your medications regularly? Anita, yes, I've been very careful with that.
[00:41 → 00:47] I take the blood pressure pills every morning and the cholesterol medication after dinner,
[00:47 → 00:54] just like you told me. Doctor Amit, excellent. Your blood pressure readings from your last visit
[00:54 → 01:00] were much improved and your ECG looks stable. I'm glad to hear you're staying consistent.
[01:00 → 01:06] Have you made any changes to your diet or physical activity? Anita, I've started eating less fried
[01:06 → 01:14] food, and I've been walking 20 minutes every evening after dinner. Doctor Amit, that's a great start.
[01:14 → 01:20] Try to increase your walking to 30 minutes if you can, at least five times a week.
[01:20 → 01:26] And keep an eye on how you feel during those walks, if you feel shortness of breath or chest
[01:26 → 01:32] pressure, slow down and let me know. Anita, got it. Should I still avoid stairs for now?
[01:33 → 01:39] Doctor Amit, you don't have to avoid them completely, but don't push yourself. Take breaks if you
[01:39 → 01:47] feel winded, and use the handrail. We'll reassess in a few weeks. Anita, all right. Do I need
[01:47 → 01:54] another test or scan soon? Doctor Amit, not immediately. I'll order a stress test for next month,
[01:54 → 01:59] just to check how your heart is responding to physical activity. In the meantime,
[01:59 → 02:06] continue the medication, walk regularly, and stick to the heart healthy diet. Anita, thank you,
[02:06 → 02:14] doctor. I feel more confident now. Doctor Amit, that's good to hear. Anita, you're doing well,
[02:14 → 02:20] just take it one step at a time. I'll see you in four weeks, and feel free to call if anything
[02:20 → 02:29] unusual comes up. Anita, we'll do. Thanks again. Doctor Amit, take care, Anita.

Clinical Notes

Subjective

  • Patient: Anita.

  • Chief Complaint: 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 improved from the last visit.
  • Stable ECG.

Assessment

  1. Cardiovascular Health: Improved blood pressure readings and stable ECG indicate positive response to current treatment plan.

  2. Exercise Tolerance: Reports fatigue and pressure while walking briskly, especially in the cold. Need to monitor for any signs of exertional symptoms.

Plan

  1. Monitoring:

  2. Order a stress test for next month to assess heart response to physical activity.

  3. Lifestyle Modifications:

  4. Encourage increasing walking duration to 30 minutes at least five times a week.
  5. Advise to monitor symptoms during walks and adjust pace accordingly.

  6. Continue with heart-healthy diet and medication regimen.

  7. Follow-Up:

  8. Schedule a follow-up appointment in four weeks to reassess symptoms and response to current management.
  9. Instruct to contact if any unusual symptoms arise before the next visit.
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