🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-30 13:00:40

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.
[00:22 → 00:28] Like walking fast, climbing stairs, or carrying groceries. Dr. Mera,
[00:28 → 00:36] I see. Can you describe this discomfort? Is it sharp, burning? Pressure like? Mr. Sharma,
[00:36 → 00:42] it feels more like pressure. Like a weight on my chest, it usually lasts a few minutes and goes
[00:42 → 00:48] away when I sit or slow down. Dr. Mera, have you noticed any accompanying symptoms?
[00:49 → 00:57] Shortness of breath, lightheadedness, sweating, or pain radiating to your arm or jaw. Mr. Sharma,
[00:57 → 01:05] yes, I do feel a little breathless, especially if I push myself. No pain in the arms or jaw,
[01:05 → 01:09] though, and I've had a few episodes where I felt a bit dizzy afterward.
[01:10 → 01:16] Dr. Mera, all right, thank you for sharing that. Let's take a look at your vitals first your
[01:16 → 01:26] blood pressure today is 142 over 88. Slightly elevated, your pulse is regular at 82 beats per minute,
[01:26 → 01:34] and your oxygen saturation is 97%. Any changes in your medication or diet recently. Mr. Sharma,
[01:34 → 01:41] I've been trying to reduce salt and walk 30 minutes daily, but I do sometimes forget my evening dose
[01:41 → 01:48] of amlota peen. Dr. Mera, that could be contributing to the elevated blood pressure. And what about your
[01:48 → 01:57] diabetes? Were you monitoring your glucose levels? Mr. Sharma, yes, I check it every morning.
[01:57 → 02:05] It's usually around 110 to 120. I haven't started medication yet. Dr. Mera, that's manageable for
[02:05 → 02:12] now, 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 an 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 to
[02:41 → 02:49] 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 → 03:03] Mr. Sharma, that sounds like a lot. Will there be any side effects I should watch out for?
[03:03 → 03:10] Dr. Mera, that's a fair concern. You might experience mild fatigue or muscle aches with the statin,
[03:10 → 03:16] but most people tolerate it well. The aspirin can occasionally cause gastritis.
[03:16 → 03:22] So I'll prescribe a gastroprotective medicine along with it. Let me know if you experience any
[03:22 → 03:31] black stools. Stomach pain or unusual bruising. Mr. Sharma, understood. Should I avoid any particular
[03:31 → 03:39] foods? Dr. Mera, yes. Continue your low sodium diet. Reduce saturated fats
[03:39 → 03:47] and increase intake of vegetables. 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 → 04:15] My team will call you to book the diagnostic appointments. In the meantime, if you experience
[04:15 → 04:22] severe chest pain, shortness of breath, or feel faint, please go to the emergency room immediately.
[04:23 → 04:32] Mr. Sharma, thank you. Dr. This was very helpful. Dr. Mera, you're welcome. Mr. Sharma,
[04:32 → 04:37] we'll stay proactive and make sure everything is under control. I'll have the nurse explain the
[04:37 → 04:46] prescriptions and testing schedule before you leave.

Clinical Notes

Subjective

  • Patient: Mr. Sharma.

  • Primary Concern: Experiencing discomfort in the chest when exerting himself, such as walking fast, climbing stairs, or carrying groceries. Describes the discomfort as pressure that lasts a few minutes and goes away when sitting or slowing down. Reports feeling breathless and dizzy on exertion.

  • Medication/Diet History: Trying to reduce salt intake and walking daily. Occasionally forgets evening dose of amlodipine. Monitors glucose levels in the morning, ranging from 110 to 120. Has not started diabetes medication yet.

Objective

  • Vitals:
  • Blood pressure: 142/88 mmHg (slightly elevated).
  • Pulse: 82 bpm.
  • Oxygen saturation: 97%.

Assessment

  1. Hypertension: Elevated blood pressure, possibly influenced by missed evening dose of amlodipine.

  2. Hyperglycemia: Morning glucose levels around 110-120, not on medication yet.

  3. Cardiovascular Risk:

  4. Chest discomfort on exertion, associated with breathlessness and dizziness, warrants further investigation.

Plan

  1. Diagnostic Tests:

  2. ECG, echocardiogram, and treadmill stress test to assess heart response under physical exertion. 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. Instructed to watch for side effects like fatigue, muscle aches with statin, and possible gastritis with aspirin. Advised to report black stools, stomach pain, or unusual bruising.

  9. Lifestyle Modifications:

  10. Maintain low sodium diet, increase vegetable and lean protein intake, and reduce saturated fats.
  11. Emphasized the importance of hydration, consistent physical activity, and avoiding smoking and limiting alcohol intake.

  12. Advised to engage in brisk walking but not to overexert until the stress test is completed.

  13. Follow-Up:

  14. Follow-up appointment in two weeks to review test results.

  15. Instructed to seek immediate medical attention if experiencing severe chest pain, shortness of breath, or faintness.

  16. Education:

  17. Nurse to provide detailed explanations of prescribed medications and testing schedule before the patient leaves.
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