🩺 Record Detail
Patient Info
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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><p><strong class="SPEAKER-01">SPEAKER-01:</strong> episodes where I felt a bit dizzy afterward. Dr. Mera, all right,</p></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><p><strong class="SPEAKER-01">SPEAKER-01:</strong> 97%. Any changes in your medication or diet recently? Mr. Sharma,</p></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> I'd like to run a few tests, specifically in ECG, an echocardiogram, and a</p></div></td></tr><tr><td id="fragmentid_20"><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_21"><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_22"><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_23"><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_24"><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_25"><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_26"><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_27"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> but most people tolerate it well. The aspirin can occasionally cause gastritis.</p></div></td></tr><tr><td id="fragmentid_28"><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_29"><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_30"><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_31"><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_32"><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_33"><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_34"><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_35"><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_36"><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_37"><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_38"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: everything is under control. I'll have the nurse explain the prescriptions and testing schedule</div></td></tr><tr><td id="fragmentid_39"><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
Patient Information: - Name: Mr. Sharma - Age: Not provided - Sex: Male - Date of Birth: Not provided - Parent/Guardian Name: Not provided - Date of Consultation: Not provided - Referring Physician: Not provided
Chief Complaint: Mr. Sharma presented with chest discomfort on exertion over the last month.
History of Present Illness (HPI): - Mr. Sharma described the discomfort in his chest as pressure, like a weight, lasting a few minutes, especially when walking fast, climbing stairs, or carrying groceries. - Denies sharp or burning pain. - No pain in arms or jaw but reported episodes of feeling dizzy afterward.
Past Medical History: - Mr. Sharma mentioned monitoring glucose levels, averaging around 110 to 120, without starting medication yet. - Admitted to forgetting evening dose of amlodipine, prescribed for elevated blood pressure.
Social History: - Mentioned following a low sodium diet and walking 30 minutes daily. - Inquired about glucose monitoring and diet changes.
Physical Examination: - Blood pressure: 142 mmHg (slightly elevated) - Pulse: 82 bpm (regular) - Oxygen saturation: 97%
Assessment: - Suspected cardiac origin of chest discomfort on exertion. - Elevated blood pressure noted. - Glucose levels within normal range but to be monitored closely.
Plan: - Ordered tests: ECG, echocardiogram, stress test to assess heart function. - Increased amlodipine dose to 10mg daily, initiated low-dose aspirin (81mg), and prescribed a statin for clot prevention. - Advised on possible side effects of medications. - Recommended dietary modifications: low sodium, reduced saturated fats, increased legumes and lean protein, no smoking, limited alcohol, and hydration. - Emphasized importance of physical activity, preferably brisk walking. - Scheduled follow-up in two weeks post-test results. - Advised to seek emergency care for severe chest pain or fainting.
Follow-up: - Follow-up appointment in two weeks post-test results. - Nurse to explain prescriptions and testing schedule before Mr. Sharma leaves.