🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-10 18:29:45

Transcript

[00:00 → 00:06] Dr. Mera, good morning, Mr. Sharma. It's good to see you again. How have you been since our
[00:06 → 00:14] last appointment in January? Mr. Sharma, good morning, Dr. I've been all right for the most part.
[00:14 → 00:21] But over the last month, I've started experiencing some discomfort in my chest when I exert myself.
[00:21 → 00:30] Like walking fast, climbing stairs, or carrying groceries. Dr. Mera, I see, can you describe
[00:30 → 00:37] this discomfort? Is it sharp? Burning? Pressure like? Mr. Sharma, it feels more like pressure.
[00:38 → 00:44] Like a weight on my chest, it usually lasts a few minutes and goes away when I sit or slow down.
[00:45 → 00:50] Dr. Mera, have you noticed any accompanying symptoms? Shortness of breath,
[00:50 → 00:59] lightheadedness, sweating, or pain radiating to your arm or jaw? Mr. Sharma, yes, I do feel a little
[00:59 → 01:06] breathless, especially if I push myself. No pain in the arms or jaw, though, and I've had
[01:06 → 01:13] a few episodes where I felt a bit dizzy afterward. Dr. Mera, all right, thank you for sharing
[01:14 → 01:20] that. Let's take a look at your vitals. First, your blood pressure today is 142 over 88.
[01:21 → 01:28] Slightly elevated. Your pulse is regular at 82 beats per minute. And your oxygen saturation
[01:28 → 01:36] is 97%. Any changes in your medication or diet recently? Mr. Sharma, I've been trying to reduce
[01:36 → 01:44] salt and walk 30 minutes daily. But I do sometimes forget my evening dose of amlota peen. Dr. Mera,
[01:44 → 01:49] that could be contributing to the elevated blood pressure. And what about your diabetes?
[01:50 → 01:57] Were you monitoring your glucose levels? Mr. Sharma, yes, I check it every morning. It's usually
[01:57 → 02:06] around 110 to 120. I haven't started medication yet. Dr. Mera, that's manageable for now,
[02:06 → 02:12] but we need to keep an eye on it. Coming back to the chest discomfort. Based on your symptoms,
[02:12 → 02:20] I'd like to run a few tests, specifically in ECG, an echocardiogram, and a treadmill stress test
[02:20 → 02:28] these will help us assess how your heart responds under physical. Exertion. Mr. Sharma, okay,
[02:28 → 02:35] do I need to get them done today? Dr. Mera, we'll schedule them within the next week. In the meantime,
[02:35 → 02:41] I'm going to make a few adjustments to your treatment plan. I'll increase your amlota peen dose
[02:41 → 02:49] to 10 milligrams once daily and start you on a low dose aspirin. 81 milligrams per day. To reduce
[02:49 → 02:56] the risk of any clot formation, I'll also prescribe a statin to help lower your LDL cholesterol.
[02:57 → 03:04] Mr. Sharma, that sounds like a lot. Will there be any side effects I should watch out for? Dr.
[03:04 → 03:10] Mera, that's a fair concern. You might experience mild fatigue or muscle aches with the statin,
[03:10 → 03:17] but most people tolerate it well. The aspirin can occasionally cause gastritis. So I'll prescribe a
[03:17 → 03:23] gastroprotective medicine along with it. Let me know if you experience any black stools.
[03:24 → 03:32] Stomach pain or unusual bruising. Mr. Sharma, understood. Should I avoid any particular foods?
[03:32 → 03:41] Dr. Mera, yes. Continue your low sodium diet. Reduce saturated fats and increase intake of vegetables.
[03:42 → 03:47] Legumes and lean protein. Avoid smoking and limit alcohol.
[03:47 → 03:54] Hydration and consistent physical activity are important too. Preferably brisk walking,
[03:54 → 04:01] but don't overexert yourself until we complete the stress test. Mr. Sharma, I'll try my best.
[04:01 → 04:08] Dr. What about follow ups? Dr. Mera, we'll see you again in two weeks once the test results are in.
[04:09 → 04:16] My team will call you to book the diagnostic appointments. In the meantime, if you experience severe
[04:16 → 04:24] chest pain, shortness of breath or feel faint, please go to the emergency room immediately. Mr. Sharma,
[04:24 → 04:33] thank you. Dr. This was very helpful. Dr. Mera, you're welcome. Mr. Sharma, we'll stay proactive and
[04:33 → 04:39] make sure everything is under control. I'll have the nurse explain the prescriptions and testing
[04:39 → 04:40] schedule before you leave.

Clinical Notes

Subjective

  • Patient: Mr. Sharma

  • Primary Concern: Experiencing chest discomfort when exerting himself, such as walking fast, climbing stairs, or carrying groceries, over the last month.

    • Describes the discomfort as pressure on the chest, lasting a few minutes and resolving when sitting or slowing down.

    • Reports feeling breathless, especially with exertion, and occasional dizziness post-exertion.

  • Medication/Diet History:

    • Trying to reduce salt intake and walking 30 minutes daily.

    • Occasionally forgets evening dose of amlodipine.

    • Monitors morning glucose levels (110-120) without medication for diabetes.

Objective

  • Vitals:

    • Blood pressure: 142/88 mmHg (slightly elevated).

    • Pulse: Regular at 82 bpm.

    • Oxygen saturation: 97%.

  • Medication/Diet:

    • Trying to reduce salt intake and increase physical activity.

    • Occasionally misses evening dose of amlodipine.

    • Morning glucose levels monitored without medication.

Assessment

  1. Cardiovascular Risk:
  2. Chest discomfort with exertion, possible angina.
  3. Elevated blood pressure.
  4. Diabetes management required.

Plan

  1. Diagnostic Tests:

  2. ECG, echocardiogram, and treadmill stress test to assess heart response under physical exertion to be scheduled within the next week.

  3. Medication Adjustments:

  4. Increase amlodipine dose to 10mg once daily.
  5. Start low-dose aspirin (81mg/day) to reduce clot formation risk.

  6. Prescribe a statin to lower LDL cholesterol.

  7. Monitoring:

  8. Advise to watch for side effects like fatigue, muscle aches with statin, and gastritis with aspirin.
  9. Prescribe gastroprotective medicine with aspirin.

  10. Instruct to report black stools, stomach pain, or unusual bruising.

  11. Lifestyle Modifications:

  12. Continue low sodium diet, reduce saturated fats, increase vegetable, legume, and lean protein intake.

  13. Avoid smoking, limit alcohol, stay hydrated, and engage in consistent physical activity.

  14. Follow-Up:

  15. Schedule a follow-up in two weeks to review test results.
  16. Nurse to explain prescriptions and testing schedule before the patient leaves.
  17. Instruct to seek emergency care for severe chest pain, shortness of breath, or fainting.
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