🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-29 12:11:12

Transcript

Doctor: Good morning, Mr. Sharma. It's good to see you again. How have you been since our last appointment in January?<br><br>Patient: Good morning, Dr. I've been all right 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.<br><br>Doctor: I see, can you describe this discomfort? Is it sharp? Burning. Pressure like?<br><br>Patient: 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.<br><br>Doctor: Have you noticed any accompanying symptoms? Shortness of breath, life-headedness, sweating, or pain radiating to your arm or jaw?<br><br>Patient: 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.<br><br>Doctor: All right, 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?<br><br>Patient: I've been trying to reduce salt and walk 30 minutes daily. But I do sometimes forget my evening dose of amlota peen.<br><br>Doctor: That could be contributing to the elevated blood pressure. And what about your diabetes? Were you monitoring your glucose levels?<br><br>Patient: Yes, I check it every morning. It's usually around 110 to 120. I haven't started medication yet.<br><br>Doctor: 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 in ECG, an echocardiogram, and a treadmill stress test these will help us assess how your heart responds under physical exertion.<br><br>Patient: Okay, do I need to get them done today?<br><br>Doctor: 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 amlota peen dose to 10 milligrams once daily and start you on a low dose aspirin. 81 milligrams per day. To reduce the risk of any clot formation, I'll also prescribe a statin to help lower your LDL cholesterol.<br><br>Patient: That sounds like a lot. Will there be any side effects I should watch out for?<br><br>Doctor: 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.<br><br>Patient: Understood. Should I avoid any particular foods?<br><br>Doctor: 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.<br><br>Patient: I'll try my best. Dr. What about follow ups?<br><br>Doctor: 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.<br><br>Patient: Thank you. Dr. this was very helpful.<br><br>Doctor: You're welcome. Mr. Sharma, 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.<br><br>

Clinical Notes

Patient Name: Mr. Sharma

Date of Visit: [Date]

CC: Chest discomfort on exertion, shortness of breath, dizziness

Subjective:

Mr. Sharma reports experiencing discomfort in his chest over the last month when exerting himself, describing it as pressure that lasts a few minutes and alleviates with rest. He also feels breathless on exertion and has experienced episodes of dizziness post-exertion. He mentions forgetting his evening dose of amlodipine and has been monitoring his morning glucose levels, ranging from 110 to 120.

Objective:

  • Blood Pressure: 142/88 mmHg
  • Pulse: 82 bpm
  • Oxygen Saturation: 97%
  • Medication: Irregular evening dose of amlodipine
  • Glucose Levels: Morning readings around 110-120

Assessment:

  • Chest discomfort on exertion, suggestive of angina
  • Elevated blood pressure, possibly exacerbated by irregular medication adherence
  • Well-controlled morning glucose levels, no medication initiated yet
  • Plan for ECG, echocardiogram, and treadmill stress test to assess cardiac function under exertion

Plan:

  1. Investigations:
  2. ECG, echocardiogram, and treadmill stress test scheduled within the next week.
  3. Medication Adjustments:
  4. Increase amlodipine dose to 10mg once daily
  5. Initiate low-dose aspirin (81mg/day) and a statin for LDL cholesterol reduction
  6. Prescribe gastroprotective medication to mitigate aspirin side effects
  7. Lifestyle Modifications:
  8. Continue low sodium diet, reduce saturated fats, increase vegetable and lean protein intake
  9. Avoid smoking, limit alcohol consumption
  10. Maintain hydration and engage in consistent physical activity, preferably brisk walking
  11. Follow-up:
  12. Follow-up appointment in two weeks to review test results
  13. Nurse to schedule diagnostic appointments
  14. Education:
  15. Advised to seek emergency care for severe chest pain, shortness of breath, or fainting

This structured plan aims to address Mr. Sharma's chest discomfort, optimize his medication regimen, and evaluate his cardiac function under stress to guide further management.

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