🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-29 05:22:03

Transcript

Doctor: Good morning, Anita. How are you feeling today? Patient: Good morning, Doctor. I'm feeling better than last month, but I still get a bit tired after climbing stairs. Doctor: 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? Patient: No pain as such, but sometimes I do feel a little pressure when I walk briskly, especially in the cold. Doctor: That could be related to exertion. Are you taking your medications regularly? Patient: 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. Doctor: 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? Patient: I've started eating less fried food, and I've been walking 20 minutes every evening after dinner. Doctor: That's a great start. Try to increase your walking to 30 minutes if you can, at least 5 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. Patient: Got it. Should I still avoid stairs for now? Doctor: 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. Patient: Alright. Do I need another test or scan soon? Doctor: 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. Patient: Thank you, Doctor. I feel more confident now. Doctor: That's good to hear, Anita. You're doing well, just take it one step at a time. I'll see you in 4 weeks, and feel free to call if anything unusual comes up. Patient: Will do. Thanks again. Doctor: Take care, Anita.

Clinical Notes

Subjective

  • Patient: Anita, age unspecified.

  • Primary Concern: Fatigue after exertion and chest pressure during brisk walking, especially in cold weather.

    • Reports feeling better than last month but still experiences tiredness after climbing stairs.
  • Lifestyle Modifications:

    • Started eating less fried food.

    • Walking 20 minutes every evening after dinner.


Objective

  • Medical History:

    • Taking blood pressure medication every morning.

    • Taking cholesterol medication after dinner.

  • Behavioral Observations:

    • Patient is compliant with medication and has made dietary changes.

    • Blood pressure readings have improved, and ECG is stable.


Assessment

  1. Exertional Fatigue: Likely due to physical activity and possibly related to cold weather.

  2. Cardiovascular Health: Stable with improved blood pressure and ECG readings.


Plan

  1. Diagnostics:

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

    • Increase walking to 30 minutes, at least 5 times a week if possible.

    • Continue heart-healthy diet and monitor for any symptoms during physical activity.

  3. Activity Recommendations:

    • Do not completely avoid stairs but take breaks if feeling winded and use handrails.
  4. Follow-Up:

    • Schedule a follow-up in 4 weeks to reassess symptoms and progress.

    • Patient advised to call if any unusual symptoms arise.

Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Blood Pressure Medication | – | unspecified | Every morning | unspecified | | Cholesterol Medication | – | unspecified | After dinner | unspecified |

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