🩺 Record Detail

Patient Info

Name: Unknown

Age: Unknown

Date: 2025-08-04 05:29:01

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Dr. Mera, good morning, Mr. Sharma. It's good to see you again. How have</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> appointment in January? Mr. Sharma, good morning, Dr. I've been all</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> But over the last month, I've started experiencing some discomfort in my chest when I exert</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Like walking fast, climbing stairs, or carrying groceries. Dr. Mera,</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> can you describe this discomfort? Is it sharp? Burning. Pressure like? Mr.</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> more like pressure. Like a weight on my chest, it usually lasts a few minutes</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> sit or slow down. Dr. Mera, have you noticed any accompanying symptoms?</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> life sweating, or pain radiating to your arm or jaw? Mr. Sharma, yes,</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> breathless, especially if I push myself. No pain in the arms or jaw,</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> episodes where I felt a bit dizzy afterward. Dr. Mera, all right,</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Let's take a look at your vitals. First, your blood pressure today is 142</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Slightly elevated. Your pulse is regular at 82 beats per minute. And your oxygen</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><tr><td id="fragmentid_22"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I'm going to make a few adjustments to your treatment plan. I'll increase your</p></div></td></tr><tr><td id="fragmentid_23"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> to 10 milligrams once daily and start you on a low dose aspirin. 81 milligrams per</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> the risk of any clot formation, I'll also prescribe a statin to help lower your</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Mr. Sharma, that sounds like a lot. Will there be any side effects I should watch out for?</p></div></td></tr><tr><td id="fragmentid_26"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Mera, that's a fair concern. You might experience mild fatigue or muscle aches with the</p></div></td></tr><tr><td id="fragmentid_27"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> but most people tolerate it well. The aspirin can occasionally cause gastritis.</p></div></td></tr><tr><td id="fragmentid_28"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> gastroprotective medicine along with it. Let me know if you experience any black</p></div></td></tr><tr><td id="fragmentid_29"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Stomach pain or unusual bruising. Mr. Sharma, understood. Should I avoid any</p></div></td></tr><tr><td id="fragmentid_30"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Dr. Mera, yes, continue your low sodium diet. Reduce saturated fats and increase</p></div></td></tr><tr><td id="fragmentid_31"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Legumes and lean protein. Avoid smoking and limit alcohol. Hydration and</p></div></td></tr><tr><td id="fragmentid_32"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> activity are important too. Preferably brisk walking, but don't overexert yourself</p></div></td></tr><tr><td id="fragmentid_33"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> complete the stress test. Mr. Sharma, I'll try my best. Dr. What about follow</p></div></td></tr><tr><td id="fragmentid_34"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> we'll see you again in two weeks once the test results are in. My team will call</p></div></td></tr><tr><td id="fragmentid_35"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> diagnostic appointments. In the meantime, if you experience severe chest pain,</p></div></td></tr><tr><td id="fragmentid_36"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> or feel faint, please go to the emergency room immediately. Mr. Sharma,</p></div></td></tr><tr><td id="fragmentid_37"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> this was very helpful. Dr. Mera, you're welcome. Mr. Sharma, we'll stay</p></div></td></tr><tr><td id="fragmentid_38"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> everything is under control. I'll have the nurse explain the prescriptions and testing</p></div></td></tr><tr><td id="fragmentid_39"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: before you leave.</div></td></tr></tbody>

Clinical Notes

SOAP Note

Subjective:

Mr. Sharma reported experiencing discomfort in his chest over the last month, particularly when exerting himself by walking fast, climbing stairs, or carrying groceries. He described the discomfort as pressure-like, feeling like a weight on his chest lasting a few minutes, relieved by rest. He denied sweating, arm or jaw pain, but mentioned feeling breathless on exertion and occasional dizziness post-exercise.

Objective:

Blood pressure: 142/__
Pulse: 82 bpm
Oxygen saturation: 97%
Mr. Sharma mentioned occasional forgetfulness of evening dose of amlodipine.
Glucose levels self-monitored around 110-120, not on medication yet.

Assessment:

Chest discomfort on exertion, suggestive of angina.
Elevated blood pressure, possibly influenced by missed evening dose of amlodipine.
Glucose levels in the pre-diabetic range, requiring monitoring.

Plan:

Investigations:
ECG, echocardiogram, and stress test scheduled within the next week to assess heart function under physical exertion.
Medication Adjustments:
Amlodipine dose increased to 10mg once daily.
Initiation of low-dose aspirin (81mg) for antiplatelet effect.
Prescribed a statin to lower cholesterol levels and reduce clot formation risk.
Gastroprotective medication to be taken with aspirin to prevent gastritis.
Lifestyle Modifications:
Maintain low sodium diet, reduce saturated fats, increase legumes and lean protein intake.
Avoid smoking, limit alcohol consumption, and prioritize hydration.
Engage in regular physical activity, preferably brisk walking without overexertion.
Follow-up:
Follow-up appointment scheduled in two weeks to review test results.
Advised to seek immediate medical attention in case of severe chest pain or fainting before the follow-up.
Education:
Nurse to provide detailed explanations regarding prescribed medications and upcoming diagnostic tests before discharge.

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