🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-21 05:52:20

Transcript

[00:00 → 00:14] Patient Rajesh is a known case of CAD, he is facing breathing problem and uneven heartbeat.
[00:14 → 00:29] BMI is normal, patient weight is 72 kg, height is 172 cm, patient is having problem in breathing,
[00:29 → 00:43] shortness of breath and breathlessness while walking. Also patient is complaining that he is feeling
[00:43 → 00:54] very dizzy after taking medicines, patient is also a known case of alcoholism, so patient is having
[00:54 → 01:08] habit of smoking, a packet of cigarette daily, and advised investigations are CBC and USG,
[01:08 → 01:20] and patient needs to follow after one week, medicines to be continued, it was prens 25 for
[01:20 → 01:37] twice daily for one week, telemarkine of 40 for one week, twice daily, and instructions,
[01:37 → 01:43] patient needs to walk regularly for at least 30 days for 30 minutes.

Clinical Notes

Subjective

  • Patient: Rajesh, known case of CAD.

  • Primary Concern:

  • Facing breathing problems, uneven heartbeat.
  • Shortness of breath and breathlessness while walking.
  • Feeling very dizzy after taking medicines.
  • Known case of alcoholism and smoking one pack of cigarettes daily.

Objective

  • Physical Examination:
  • BMI is normal.
  • Weight: 72 kg, Height: 172 cm.

Assessment

  1. Coronary Artery Disease (CAD): Known case presenting with breathing difficulties and irregular heartbeat.

  2. Alcoholism and Smoking: Contributing factors to the patient's current health issues.

Plan

  1. Medications:
  2. Prenis 25, twice daily for one week.

  3. Telemarkine 40, twice daily for one week.

  4. Investigations:

  5. CBC.

  6. USG.

  7. Follow-Up:

  8. Patient needs to follow up after one week.
  9. Instructed to continue medications.
  10. Advised to walk regularly for at least 30 minutes daily for 30 days.
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