🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-08-04 07:20:16
Transcript
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<tbody><tr><td id="fragmentid_1"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Dr. Mera, good morning, Mr. Sharma. It's good to see you again. How have</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> appointment in January? Mr. Sharma, good morning, Dr. I've been all</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> But over the last month, I've started experiencing some discomfort in my chest when I exert</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Like walking fast, climbing stairs, or carrying groceries. Dr. Mera,</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> can you describe this discomfort? Is it sharp? Burning. Pressure like? Mr.</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> more like pressure. Like a weight on my chest, it usually lasts a few minutes</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> sit or slow down. Dr. Mera, have you noticed any accompanying symptoms?</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> life sweating, or pain radiating to your arm or jaw? Mr. Sharma, yes,</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> breathless, especially if I push myself. No pain in the arms or jaw,</p></div></td></tr><tr><td id="fragmentid_10"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: episodes where I felt a bit dizzy afterward. Dr. Mera, all right, thank you for sharing that.</div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Let's take a look at your vitals. First, your blood pressure today is 142</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Slightly elevated. Your pulse is regular at 82 beats per minute. And your oxygen</p></div></td></tr><tr><td id="fragmentid_13"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: 97%. Any changes in your medication or diet recently? Mr. Sharma, I've been trying to reduce</div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> salt and walk 30 minutes daily. But I do sometimes forget my evening dose of amlota peen.</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> that could be contributing to the elevated blood pressure. And what about your</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Were you monitoring your glucose levels? Mr. Sharma, yes, I check it</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> around 110 to 120. I haven't started medication yet. Dr. Mera, that's</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> but we need to keep an eye on it. Coming back to the chest discomfort. Based on</p></div></td></tr><tr><td id="fragmentid_19"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> these will help us assess how your heart responds under physical. Exertion. Mr.</p></div></td></tr><tr><td id="fragmentid_20"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> do I need to get them done today? Dr. Mera, we'll schedule them within the next week.</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I'm going to make a few adjustments to your treatment plan. I'll increase your</p></div></td></tr><tr><td id="fragmentid_22"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> to 10 milligrams once daily and start you on a low dose aspirin. 81 milligrams per</p></div></td></tr><tr><td id="fragmentid_23"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> the risk of any clot formation, I'll also prescribe a statin to help lower your</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Mr. Sharma, that sounds like a lot. Will there be any side effects I should watch out for?</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Mera, that's a fair concern. You might experience mild fatigue or muscle aches with the</p></div></td></tr><tr><td id="fragmentid_26"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> gastroprotective medicine along with it. Let me know if you experience any black</p></div></td></tr><tr><td id="fragmentid_27"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Stomach pain or unusual bruising. Mr. Sharma, understood. Should I avoid any</p></div></td></tr><tr><td id="fragmentid_28"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Dr. Mera, yes, continue your low sodium diet. Reduce saturated fats and increase</p></div></td></tr><tr><td id="fragmentid_29"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Legumes and lean protein. Avoid smoking and limit alcohol. Hydration and</p></div></td></tr><tr><td id="fragmentid_30"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> activity are important too. Preferably brisk walking, but don't overexert yourself</p></div></td></tr><tr><td id="fragmentid_31"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> complete the stress test. Mr. Sharma, I'll try my best. Dr. What about follow</p></div></td></tr><tr><td id="fragmentid_32"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> we'll see you again in two weeks once the test results are in. My team will call</p></div></td></tr><tr><td id="fragmentid_33"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> diagnostic appointments. In the meantime, if you experience severe chest pain,</p></div></td></tr><tr><td id="fragmentid_34"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> or feel faint, please go to the emergency room immediately. Mr. Sharma,</p></div></td></tr><tr><td id="fragmentid_35"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> this was very helpful. Dr. Mera, you're welcome. Mr. Sharma, we'll stay</p></div></td></tr><tr><td id="fragmentid_36"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> everything is under control. I'll have the nurse explain the prescriptions and testing</p></div></td></tr><tr><td id="fragmentid_37"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: before you leave.</div></td></tr></tbody>
Clinical Notes
SOAP Note
Subjective:
- Chief Complaint: Mr. Sharma reports experiencing discomfort in his chest over the last month, especially during activities like walking fast, climbing stairs, or carrying groceries. He describes the discomfort as pressure lasting a few minutes.
- History of Present Illness: Denies pain radiating to the arm or jaw but mentions feeling breathless at times, especially with exertion. Reports episodes of feeling dizzy afterward.
- Medications: Occasionally forgets the evening dose of amlodipine.
- Glucose Levels: Self-monitored around 110 to 120, not on medication yet.
Objective:
- Vitals: Blood pressure 142/90 mmHg, pulse 82 bpm, oxygen saturation 97%.
- Medication/Diet Changes: Trying to reduce salt intake and walking daily. Occasionally forgets amlodipine dose.
Assessment:
- Cardiac Discomfort: Chest discomfort with exertion, slightly elevated blood pressure, and ongoing monitoring of glucose levels. Risk factors for cardiovascular disease.
Plan:
- Adjustments to Treatment Plan:
- Increase amlodipine to 10 mg once daily.
- Start low-dose aspirin (81 mg) for clot prevention.
- Prescribe a statin for lowering cholesterol.
- Lifestyle Recommendations:
- Continue low sodium diet, reduce saturated fats, increase legumes and lean protein.
- Avoid smoking, limit alcohol intake.
- Emphasize hydration and physical activity, preferably brisk walking.
- Diagnostic Testing:
- Schedule stress test within the next week to assess heart response under exertion.
- Follow-up:
- Schedule a follow-up appointment in two weeks to review test results.
- Advised to seek immediate medical attention for severe chest pain or fainting.