🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-08-05 17:34:29
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><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: but we need to keep an eye on it. Coming back to the chest discomfort. Based on your symptoms,</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><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: do I need to get them done today? Dr. Mera, we'll schedule them within the next week. In the meantime,</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><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Mr. Sharma, that sounds like a lot. Will there be any side effects I should watch out for? Dr.</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
Patient Identifying Information: - Patient Name: Mr. Sharma
Chief Complaint: - Experiencing discomfort in the chest during exertion.
History of Presenting Illness: - Mr. Sharma reports chest discomfort when walking fast, climbing stairs, or carrying groceries. - Describes the discomfort as pressure lasting a few minutes, prompting him to sit or slow down. - Denies pain in the arms or jaw but mentions feeling breathless and dizzy after exertion.
Symptoms: - Chest discomfort - Breathlessness - Dizziness
Past Medical History: - Hypertension - Monitoring glucose levels (110-120) without medication
Medications: - Amlodipine (evening dose occasionally forgotten)
Assessment: - Elevated blood pressure at 142/___ mmHg. - Regular pulse at 82 bpm. - Oxygen saturation at 97%. - Glucose levels monitored without medication. - Symptoms suggestive of cardiovascular concern.
Plan: - Order tests: ECG, echocardiogram, stress test to assess heart function. - Adjust treatment plan: Increase amlodipine to 10mg daily, start low-dose aspirin (81mg), prescribe a statin. - Advise on potential side effects: mild fatigue, muscle aches, gastritis with aspirin. - Emphasize dietary modifications: low sodium, reduced saturated fats, increased legumes and lean protein, no smoking, limited alcohol, hydration, and regular activity. - Follow-up in two weeks for test results review. - Instruct to seek emergency care for severe chest pain or fainting. - Nurse to provide detailed explanation of prescriptions and testing before discharge.