🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-07-24 05:39:48
Transcript
<p><strong>Doctor1</strong>: Good morning, Mr. Sharma. It's good to see you again. How have you been since our last appointment in January?</p><p><strong>Patient</strong>: Good morning, Dr. I've been all right for the most part. But over the last month, I've started experiencing some discomfort in my chest when I exert myself. Like walking fast, climbing stairs, or carrying groceries.</p><p><strong>Doctor</strong>: I see, can you describe this discomfort? Is it sharp? Burning? Pressure like?</p><p><strong>Patient</strong>: It feels more like pressure. Like a weight on my chest, it usually lasts a few minutes and goes away when I sit or slow down.</p><p><strong>Doctor</strong>: Have you noticed any accompanying symptoms? Shortness of breath, lightheadedness, sweating, or pain radiating to your arm or jaw?</p><p><strong>Patient</strong>: Yes, I do feel a little breathless, especially if I push myself. No pain in the arms or jaw, though, and I've had a few episodes where I felt a bit dizzy afterward.</p><p><strong>Doctor</strong>: All right, thank you for sharing that. Let's take a look at your vitals first your blood pressure today is 142 over 88. Slightly elevated, your pulse is regular at 82 beats per minute, and your oxygen saturation is 97%. Any changes in your medication or diet recently?</p><p><strong>Patient</strong>: I've been trying to reduce salt and walk 30 minutes daily, but I do sometimes forget my evening dose of amlota peen.</p><p><strong>Doctor</strong>: That could be contributing to the elevated blood pressure, and what about your diabetes? Were you monitoring your glucose levels?</p><p><strong>Patient</strong>: Yes, I check it every morning. It's usually around 110 to 120. I haven't started medication yet.</p><p><strong>Doctor</strong>: That's manageable for now, but we need to keep an eye on it. Coming back to the chest discomfort, based on your symptoms, I'd like to run a few tests, specifically in ECG, an echocardiogram, and a treadmill stress test these will help us assess how your heart responds under physical exertion.</p><p><strong>Patient</strong>: Okay, do I need to get them done today?</p><p><strong>Doctor</strong>: We'll schedule them within the next week. In the meantime, I'm going to make a few adjustments to your treatment plan. I'll increase your amlota peen dose to 10 milligrams once daily and start you on a low dose aspirin, 81 milligrams per day, to reduce the risk of any clot formation. I'll also prescribe a statin to help lower your LDL cholesterol.</p><p><strong>Patient</strong>: That sounds like a lot. Will there be any side effects I should watch out for?</p><p><strong>Doctor</strong>: That's a fair concern. You might experience mild fatigue or muscle aches with the statin, but most people tolerate it well. The aspirin can occasionally cause gastritis. So I'll prescribe a gastroprotective medicine along with it. Let me know if you experience any black stools. Stomach pain or unusual bruising.</p><p><strong>Patient</strong>: Understood, should I avoid any particular foods?</p><p><strong>Doctor</strong>: Yes, continue your low sodium diet, reduce saturated fats, and increase intake of vegetables, legumes, and lean protein, avoid smoking and limit alcohol. Hydration and consistent physical activity are important too. Preferably brisk walking, but don't overexert yourself until we complete the stress test.</p><p><strong>Patient</strong>: I'll try my best. Dr. What about follow ups?</p><p><strong>Doctor</strong>: We'll see you again in two weeks once the test results are in. My team will call you to book the diagnostic appointments. In the meantime, if you experience severe chest pain, shortness of breath, or feel faint, please go to the emergency room immediately.</p><p><strong>Patient</strong>: Thank you. Dr. This was very helpful.</p><p><strong>Doctor</strong>: You're welcome. Mr. Sharma, we'll stay proactive and make sure everything is under control. I'll have the nurse explain the prescriptions and testing schedule before you leave.</p>
Clinical Notes
Subjective
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Patient: Mr. Sharma.
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Primary Concern: Experiencing chest discomfort when exerting himself, such as walking fast, climbing stairs, or carrying groceries. Describes the discomfort as pressure on the chest, lasting a few minutes and relieved by rest.
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Associated Symptoms:
- Reports feeling breathless, especially with exertion.
- Episodes of dizziness post-exertion.
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Medication and Lifestyle:
- Trying to reduce salt intake and walking 30 minutes daily.
- Occasionally forgets evening dose of amlodipine.
- Monitors morning glucose levels (110-120 mg/dL) without medication.
- Concerned about potential side effects of prescribed medications.
Objective
- Vitals:
- Blood pressure: 142/88 mmHg.
- Pulse: 82 bpm.
- Oxygen saturation: 97%.
Assessment
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Chest Discomfort:
- Likely angina pectoris based on exertional chest pressure and associated breathlessness.
- Differential diagnosis includes musculoskeletal pain, gastroesophageal reflux disease (GERD), or anxiety.
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Hypertension:
- Elevated blood pressure of 142/88 mmHg.
- Non-adherence to evening amlodipine dose may contribute.
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Hyperglycemia:
- Morning glucose levels of 110-120 mg/dL.
- Pre-diabetic range, requiring close monitoring.
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Hyperlipidemia:
- Statin prescribed to lower LDL cholesterol levels.
Plan
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Diagnostic Tests:
- Schedule ECG, echocardiogram, and treadmill stress test to evaluate cardiac function and response to exertion.
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Medication Adjustments:
- Increase amlodipine dose to 10 mg once daily.
- Initiate low-dose aspirin (81 mg) for antiplatelet effect.
- Prescribe statin for hyperlipidemia.
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Lifestyle Modifications:
- Emphasize low sodium diet, reduced saturated fats, and increased intake of vegetables, legumes, and lean protein.
- Encourage smoking cessation, limited alcohol intake, hydration, and consistent physical activity.
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Monitoring:
- Follow-up appointment in two weeks to review test results.
- Nurse to schedule diagnostic appointments.
- Instructed to seek emergency care for severe chest pain, shortness of breath, or fainting.