🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-04 19:39:30

Transcript

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{"type": "transcription", "speaker": "Identifying", "segmentId": "811aec8c-8f70-419f-8410-19f73ef3bd6e", "text": "last appointment in January? Mr. Sharma. Good morning, doctor. I've been alright for the most", "start": "00:06", "end": "00:13", "start_sec": 6.8, "end_sec": 13.94, "roman": "last appointment in January? Mr. Sharma. Good morning, doctor. I've been alright for the most", "native": "last appointment in January? Mr. Sharma. Good morning, doctor. I've been alright for the most", "nativeScript": "Latin", "romanDiffersFromNative": false}
{"type": "transcription", "speaker": "Identifying", "segmentId": "3e102a1a-ff52-4eb1-9d9d-7dae9bab3c29", "text": "part. But over the last month, I've started experiencing some discomfort in my chest when", "start": "00:13", "end": "00:20", "start_sec": 13.94, "end_sec": 20.06, "roman": "part. But over the last month, I've started experiencing some discomfort in my chest when", "native": "part. But over the last month, I've started experiencing some discomfort in my chest when", "nativeScript": "Latin", "romanDiffersFromNative": false}
{"type": "transcription", "speaker": "Identifying", "segmentId": "15b765d1-62c8-4d7c-90a6-9ffa6a4f09ba", "text": "I exert myself. Like walking fast, climbing stairs, or carrying groceries. Dr. Mera. I see.", "start": "00:20", "end": "00:28", "start_sec": 20.06, "end_sec": 28.94, "roman": "I exert myself. Like walking fast, climbing stairs, or carrying groceries. Dr. Mera. I see.", "native": "I exert myself. Like walking fast, climbing stairs, or carrying groceries. Dr. Mera. I see.", "nativeScript": "Latin", "romanDiffersFromNative": false}
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{"type": "finalTranscript", "data": {"transcript": [{"speaker": "Doctor", "text": "Good morning, Mr. Sharma. It's good to see you again. How have you been since our last appointment in January?"}, {"speaker": "Patient", "text": "Good morning, doctor. I've been alright 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."}, {"speaker": "Doctor", "text": "I see. Can you describe this discomfort? Is it sharp? Burning? Pressure-like?"}, {"speaker": "Patient", "text": "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."}, {"speaker": "Doctor", "text": "Have you noticed any accompanying symptoms? Shortness of breath? Lightheadedness? Sweating? Or pain radiating to your arm or jaw?"}, {"speaker": "Patient", "text": "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."}, {"speaker": "Doctor", "text": "Alright, 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?"}, {"speaker": "Patient", "text": "I've been trying to reduce salt and walk 30 minutes daily. But I do sometimes forget my evening dose of amlodipine."}, {"speaker": "Doctor", "text": "That could be contributing to the elevated blood pressure. And what about your diabetes? Were you monitoring your glucose levels?"}, {"speaker": "Patient", "text": "Yes. I check it every morning. It's usually around 110 to 120. I haven't started medication yet."}, {"speaker": "Doctor", "text": "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 an ECG. An echocardiogram. And a treadmill stress test. These will help us assess how your heart responds under physical exertion."}, {"speaker": "Patient", "text": "Okay. Do I need to get them done today?"}, {"speaker": "Doctor", "text": "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 amlodipine dose to 10mg once daily and start you on a low-dose aspirin. 81mg per day. To reduce the risk of any clot formation. I'll also prescribe a statin to help lower your LDL cholesterol."}, {"speaker": "Patient", "text": "That sounds like a lot. Will there be any side effects I should watch out for?"}, {"speaker": "Doctor", "text": "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."}, {"speaker": "Patient", "text": "Understood. Should I avoid any particular foods?"}, {"speaker": "Doctor", "text": "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."}, {"speaker": "Patient", "text": "I'll try my best. What about follow-ups?"}, {"speaker": "Doctor", "text": "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."}, {"speaker": "Patient", "text": "Thank you, doctor. This was very helpful."}, {"speaker": "Doctor", "text": "You're welcome. 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."}], "speakers": {"Doctor": "Usually asks diagnostic questions or gives medical instructions", "Patient": "Usually describes symptoms or answers", "Family Member": "Third-party participant when contextually clear"}}, "isFinal": true}

Clinical Notes

Subjective

  • Patient: Mr. Sharma

  • Primary Concern: Chest discomfort when exerting himself.

    • Experiences discomfort during activities like walking fast, climbing stairs, or carrying groceries.

    • Describes the discomfort as pressure-like, similar to a weight on the chest, lasting a few minutes and relieved by rest.

  • Accompanying Symptoms:

    • Shortness of breath, especially upon exertion.

    • Occasional dizziness after exertion.

    • No pain radiating to arms or jaw.

  • Lifestyle Factors:

    • Attempting to reduce salt intake and walk 30 minutes daily.

    • Occasionally forgets evening dose of amlodipine.

  • Medical History:

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

    • Pulse: Regular at 82 beats per minute.

    • Oxygen saturation: 97%.

    • Glucose levels: Typically 110-120 mg/dL, not on diabetes medication yet.


Objective

  • Medical History:

    • Currently on amlodipine, but occasionally misses doses.

    • No current diabetes medication.

  • Behavioral Observations:

    • Patient expresses concern about the number of medications and potential side effects.

Assessment

  1. Hypertension: Likely exacerbated by missed doses of amlodipine and lifestyle factors.

  2. Chest Discomfort: Possibly angina, requires further investigation.

  3. Diabetes: Currently managed without medication, but requires monitoring.


Plan

  1. Diagnostics:

    • Schedule ECG, echocardiogram, and treadmill stress test to assess heart function.
  2. Medication Adjustments:

    • Increase amlodipine to 10mg once daily.

    • Start low-dose aspirin (81mg daily) for clot prevention.

    • Prescribe a statin to lower LDL cholesterol.

    • Prescribe gastroprotective medicine to prevent gastritis from aspirin.

  3. Lifestyle Modifications:

    • Continue low-sodium diet, reduce saturated fats, and increase intake of vegetables, legumes, and lean protein.

    • Avoid smoking and limit alcohol.

    • Maintain hydration and engage in consistent physical activity, preferably brisk walking, without overexertion until stress test is completed.

  4. Follow-Up:

    • Schedule follow-up in two weeks to review test results.

    • Instruct patient to seek emergency care if experiencing severe chest pain, shortness of breath, or fainting.

Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Amlodipine | – | 10mg | Once daily | unspecified | | Aspirin | – | 81mg | Once daily | unspecified | | Statin | – | unspecified | unspecified | unspecified | | Gastroprotective | – | unspecified | unspecified | unspecified |

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