🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-09-23 09:11:25
Transcript
Doctor: Good morning, Anita. How are you feeling today? Patient: Good morning, Doctor. I'm feeling better than last month, but I still get a bit tired after climbing stairs. Doctor: I see. That's actually helpful to know. Let's go over a few things. How's the chest discomfort? Any pain or tightness recently? Patient: No pain as such, but sometimes I do feel a little pressure when I walk briskly, especially in the cold. Doctor: That could be related to exertion. Are you taking your medications regularly? Patient: Yes, I've been very careful with that. I take the blood pressure pills every morning and the cholesterol medication after dinner, just like you told me. Doctor: Excellent. Your blood pressure readings from your last visit were much improved, and your ECG looks stable. I'm glad to hear you're staying consistent. Have you made any changes to your diet or physical activity? Patient: I've started eating less fried food, and I've been walking 20 minutes every evening after dinner. Doctor: That's a great start. Try to increase your walking to 30 minutes if you can, at least 5 times a week. And keep an eye on how you feel during those walks, if you feel shortness of breath or chest pressure, slow down and let me know. Patient: Got it. Should I still avoid stairs for now? Doctor: You don't have to avoid them completely, but don't push yourself. Take breaks if you feel winded, and use the handrail. We'll reassess in a few weeks. Patient: Alright. Do I need another test or scan soon? Doctor: Not immediately. I'll order a stress test for next month, just to check how your heart is responding to physical activity. In the meantime, continue the medication, walk regularly, and stick to the heart healthy diet. Patient: Thank you, Doctor. I feel more confident now. Doctor: That's good to hear, Anita. You're doing well, just take it one step at a time. I'll see you in 4 weeks, and feel free to call if anything unusual comes up. Patient: Will do. Thanks again. Doctor: Take care, Anita.
Clinical Notes
Allergies
No significant allergy history.
Chief Complaints / HOPI / Examination
- Occasional chest pressure during brisk walking, especially in cold weather
- Improved blood pressure readings
- Stable ECG
- Patient experiences fatigue after climbing stairs
Provisional Diagnosis/Diagnosis:
- NA
Investigations / Medication Advised
Laboratory:
- NA
Radiology:
- Stress test scheduled for next month
Medication
| Sr. | Drug Name | Route | Dose | Frequency | Duration | Remarks |
|---|---|---|---|---|---|---|
| 1 | Blood pressure medication | Oral | - | Once daily | - | Taken every morning |
| 2 | Cholesterol medication | Oral | - | Once daily | - | Taken after dinner |
Advice / Follow-Up
- Continue current medications
- Increase walking to 30 minutes, at least 5 times a week
- Monitor for shortness of breath or chest pressure during walks
- Use handrail and take breaks when using stairs
- Follow a heart-healthy diet
- Follow-up in 4 weeks