🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-18 05:00:18

Transcript

[00:00 → 00:06] Dr. Mera, good morning, Mr. Sharma. It's good to see you again. How have you been since our
[00:06 → 00:14] last appointment in January? Mr. Sharma, good morning, Dr. I've been all right for the most part.
[00:14 → 00:21] But over the last month, I've started experiencing some discomfort in my chest when I exert myself.
[00:21 → 00:30] Like walking fast, climbing stairs, or carrying groceries. Dr. Mera, I see, can you describe
[00:30 → 00:37] this discomfort? Is it sharp? Burning? Pressure like? Mr. Sharma, it feels more like pressure.
[00:38 → 00:44] Like a weight on my chest, it usually lasts a few minutes and goes away when I sit or slow down.
[00:45 → 00:50] Dr. Mera, have you noticed any accompanying symptoms? Shortness of breath,
[00:50 → 00:59] lightheadedness, sweating, or pain radiating to your arm or jaw? Mr. Sharma, yes, I do feel a little
[00:59 → 01:06] breathless, especially if I push myself. No pain in the arms or jaw, though, and I've had
[01:06 → 01:13] a few episodes where I felt a bit dizzy afterward. Dr. Mera, all right, thank you for sharing
[01:14 → 01:20] that. Let's take a look at your vitals. First, your blood pressure today is 142 over 88.
[01:21 → 01:28] Slightly elevated. Your pulse is regular at 82 beats per minute. And your oxygen saturation
[01:28 → 01:36] is 97%. Any changes in your medication or diet recently? Mr. Sharma, I've been trying to reduce
[01:36 → 01:44] salt and walk 30 minutes daily. But I do sometimes forget my evening dose of amlota peen. Dr. Mera,
[01:44 → 01:49] that could be contributing to the elevated blood pressure. And what about your diabetes?
[01:50 → 01:57] Were you monitoring your glucose levels? Mr. Sharma, yes, I check it every morning. It's usually
[01:57 → 02:06] around 110 to 120. I haven't started medication yet. Dr. Mera, that's manageable for now,
[02:06 → 02:12] but we need to keep an eye on it. Coming back to the chest discomfort. Based on your symptoms,
[02:12 → 02:20] I'd like to run a few tests, specifically in ECG, an echocardiogram, and a treadmill stress test
[02:20 → 02:28] these will help us assess how your heart responds under physical. Exertion. Mr. Sharma, okay,
[02:28 → 02:35] do I need to get them done today? Dr. Mera, we'll schedule them within the next week. In the meantime,
[02:35 → 02:41] I'm going to make a few adjustments to your treatment plan. I'll increase your amlota peen dose
[02:41 → 02:49] to 10 milligrams once daily and start you on a low dose aspirin. 81 milligrams per day. To reduce
[02:49 → 02:56] the risk of any clot formation, I'll also prescribe a statin to help lower your LDL cholesterol.
[02:57 → 03:04] Mr. Sharma, that sounds like a lot. Will there be any side effects I should watch out for? Dr.
[03:04 → 03:10] Mera, that's a fair concern. You might experience mild fatigue or muscle aches with the statin,
[03:10 → 03:17] but most people tolerate it well. The aspirin can occasionally cause gastritis. So I'll prescribe a
[03:17 → 03:23] gastroprotective medicine along with it. Let me know if you experience any black stools.
[03:24 → 03:32] Stomach pain or unusual bruising. Mr. Sharma, understood. Should I avoid any particular foods?
[03:32 → 03:41] Dr. Mera, yes. Continue your low sodium diet. Reduce saturated fats and increase intake of vegetables.
[03:42 → 03:47] Legumes and lean protein. Avoid smoking and limit alcohol.
[03:47 → 03:54] Hydration and consistent physical activity are important too. Preferably brisk walking,
[03:54 → 04:01] but don't overexert yourself until we complete the stress test. Mr. Sharma, I'll try my best.
[04:01 → 04:08] Dr. What about follow ups? Dr. Mera, we'll see you again in two weeks once the test results are in.
[04:09 → 04:16] My team will call you to book the diagnostic appointments. In the meantime, if you experience severe
[04:16 → 04:24] chest pain, shortness of breath or feel faint, please go to the emergency room immediately. Mr. Sharma,
[04:24 → 04:33] thank you. Dr. This was very helpful. Dr. Mera, you're welcome. Mr. Sharma, we'll stay proactive and
[04:33 → 04:39] make sure everything is under control. I'll have the nurse explain the prescriptions and testing
[04:39 → 04:40] schedule before you leave.

Clinical Notes

Subjective

  • Patient: Mr. Sharma.

  • Primary Concern: Experiencing discomfort in the chest when exerting himself, such as walking fast, climbing stairs, or carrying groceries. Describes the discomfort as pressure, lasting a few minutes, and relieved by sitting or slowing down. Reports feeling breathless and dizzy during exertion.

  • Medication/Diet History:

  • Trying to reduce salt intake and walking 30 minutes daily.
  • Occasionally forgets evening dose of amlodipine.
  • Monitors morning glucose levels (around 110 to 120) without medication for diabetes.

Objective

  • Vitals:
  • Blood pressure: 142/88 mmHg (slightly elevated).
  • Pulse: 82 bpm.
  • Oxygen saturation: 97%.

Assessment

  1. Cardiovascular Symptoms: Chest discomfort with exertion, associated with breathlessness and dizziness, warrants further investigation.
  2. Hypertension: Slightly elevated blood pressure, possibly influenced by missed amlodipine doses.
  3. Hyperglycemia: Morning glucose levels around 110 to 120, requiring monitoring.

Plan

  1. Diagnostics:

  2. Schedule ECG, echocardiogram, and treadmill stress test within the next week to evaluate heart response during physical exertion.

  3. Medication Adjustments:

  4. Increase amlodipine dose to 10 mg once daily.
  5. Initiate low-dose aspirin (81 mg/day) to reduce clot formation risk.

  6. Prescribe a statin to lower LDL cholesterol levels.

  7. Monitoring:

  8. Advise to watch for side effects like fatigue, muscle aches with the statin, and potential gastritis with aspirin.
  9. Prescribe gastroprotective medication to mitigate aspirin-related gastrointestinal issues.

  10. Instruct to report any black stools, stomach pain, or unusual bruising.

  11. Lifestyle Modifications:

  12. Continue low sodium diet, reduce saturated fats, and increase intake of vegetables, legumes, and lean protein.
  13. Encourage hydration, consistent physical activity (preferably brisk walking), and smoking cessation.

  14. Limit alcohol intake and avoid overexertion until the stress test is completed.

  15. Follow-Up:

  16. Schedule a follow-up appointment in two weeks to review test results.
  17. Nurse to provide information on prescriptions and testing schedule before the patient leaves the clinic.
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