🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-28 07:18:41

Transcript

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                                                   <th><strong>Original Transcription</strong></th>
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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">Doctor</strong>: Good morning, Mr. Sharma. It's good to see you again. How have you been since our last appointment in January?</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="Patient">Patient</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="Doctor">Doctor</strong>: I see. Can you describe this discomfort? Is it sharp? Burning? Pressure-like?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="Patient">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></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="Doctor">Doctor</strong>: Have you noticed any accompanying symptoms? Shortness of breath? Lightheadedness? Sweating? Or pain radiating to your arm or jaw?</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="Patient">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></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="Doctor">Doctor</strong>: 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?</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="Patient">Patient</strong>: I've been trying to reduce salt and walk 30 minutes daily. But I do sometimes forget my evening dose of amlodipine.</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="Doctor">Doctor</strong>: That could be contributing to the elevated blood pressure. And what about your diabetes? Were you monitoring your glucose levels?</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="Patient">Patient</strong>: Yes. I check it every morning. It's usually around 110 to 120. I haven't started medication yet.</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="Doctor">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 an ECG. An echocardiogram. And a treadmill stress test. These will help us assess how your heart responds under physical exertion.</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="Patient">Patient</strong>: Okay. Do I need to get them done today?</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="Doctor">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 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.</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="Patient">Patient</strong>: That sounds like a lot. Will there be any side effects I should watch out for?</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="Doctor">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></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="Patient">Patient</strong>: Understood. Should I avoid any particular foods?</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="Doctor">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></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="Patient">Patient</strong>: I'll try my best. What about follow-ups?</p></div></td></tr><tr><td id="fragmentid_19"><div><p><strong class="Doctor">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></div></td></tr><tr><td id="fragmentid_20"><div><p><strong class="Patient">Patient</strong>: Thank you, doctor. This was very helpful.</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="Doctor">Doctor</strong>: 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.</p></div></td></tr></tbody>

Clinical Notes

Standardized Dietitian Consult Report
Patient Name: Mr. Sharma
Date of Visit: SESSION_DATE
Chief Complaint (CC): Chest discomfort during exertion, shortness of breath, dizziness.
Dietary History:
• Typical Diet: Not specified
• Breakfast: Not specified
• Lunch: Not specified
• Dinner: Not specified
• Snacks: Not specified
• Fruit and Vegetable Intake: Advised to increase intake.
• Processed Food Intake: Advised to reduce saturated fats.
• Water Intake: Emphasized importance of hydration.
• Lactose Intolerance: Not specified

Medical History:
• Hypertension: Managed with amlodipine.
• Diabetes: Monitoring glucose levels, not on medication yet.

Medications:
• Amlodipine: Increased to 10mg once daily for hypertension.
• Aspirin: 81mg per day to reduce clot formation risk.
• Statin: Prescribed to lower LDL cholesterol.
• Gastroprotective medicine: To prevent gastritis from aspirin.

Allergies:
• None: Not specified

Social History:
• Exercise: Walking 30 minutes daily.
• Smoking: Advised to avoid.

Family History:
• Not specified

Review of Systems (ROS):
• Cardiovascular: Chest discomfort, pressure-like sensation.
• Respiratory: Shortness of breath on exertion.
• Neurological: Episodes of dizziness.

Nutritional Assessment:
• BMI: [Insert BMI] (calculated based on weight and height provided).
• BMI Category: [Insert BMI category] (e.g., overweight, obese).

Body Composition Analysis: Not performed during this visit.
Dietary Intake Analysis: To be completed based on dietary recommendations.

Nutritional Requirements: Not specified in the provided transcript.

Nutrition Diagnosis:
• Possible Nutrient Deficiencies: Due to advised dietary changes.

Diet and Meal Planning:
• Recommendations: Continue low-sodium diet, reduce saturated fats, increase vegetables, legumes, and lean protein intake.

Nutritional Counseling:
• Recommendations: Guidance on meal planning, portion control, and healthy food choices.

Nutritional Education:
• Topics: Importance of balanced diet, hydration, and the role of fruits, vegetables, and whole grains in a healthy diet.

Specialized Diet Recommendations:
• Low-Sodium Diet: Continue as advised.

Weight Management Strategies:
• Recommendations: Encourage regular physical activity, preferably brisk walking, but avoid overexertion until stress test is completed.

Prognosis: Good with adherence to recommended dietary and lifestyle changes.

Follow-up Plan:
• Schedule: Follow-up appointment in two weeks to discuss test results and progress.

Patient Education:
• Topics: Importance of a healthy diet, hydration, and regular physical activity for overall health and well-being.

Consultation Recommendations:
• Diagnostic Tests: ECG, echocardiogram, and treadmill stress test to assess heart response under exertion.

Referral Recommendations:
• None: No referrals indicated at this time.

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