Reselect Difficulty Level
Level One Topic
- Level One
- October 12, 2023
Bangla Translation.
Below is an example Patient Encounter Document based on the transcript you just heard:
Patient Encounter Document
Cardiologist: Dr. John Parker
Date: October 12, 2023
Patient: John Smith
DOB: July 8, 1957
Medical Record Number: 987654321
Chief Complaint: Mr. Smith presented with complaints of chest pain and associated symptoms.
History of Present Illness: Mr. Smith, a 66-year-old male, reported experiencing chest pain for the past several weeks. He described the pain as a squeezing sensation located in the center of his chest, radiating to the left arm, rated at 6-7/10 in intensity. The pain is typically triggered by physical activity, such as gardening or climbing stairs, and is associated with shortness of breath, dizziness, and occasional nausea.
Past Medical History:
1. Hypertension, treated with lisinopril.
2. Non-smoker.
3. Occasional alcohol consumption.
4. No known allergies to medications.
Family History: Father had a heart attack in his early 60s, and mother has a history of hypertension.
Medications:
1. Lisinopril for hypertension.
Assessment and Plan: Based on Mr. Smith’s presentation, risk factors, and physical examination, there is a concern for possible cardiac involvement. The following steps have been taken:
1. EKG: An EKG was performed, which showed ST-segment depression in leads II, III, and aVF. Cardiac enzymes were ordered and revealed elevated troponin levels.
2. Medication Adjustment: Mr. Smith will continue lisinopril for hypertension management.
3. Nitroglycerin: Nitroglycerin has been recommended for chest pain relief as needed, and proper instructions were provided.
4. Stress Test: A stress test is scheduled to assess cardiac function and exercise tolerance.
5. Cardiology Consultation: Mr. Smith will be referred to a cardiologist for further evaluation and consideration of coronary angiography.
Follow-up: Mr. Smith is scheduled for a stress test on XXXXXXXX. He is instructed to call 911 if he experiences severe chest pain before this appointment.
Scribe: [Name]
Supervisor: Dr. John Parker
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Reselect Difficulty Level
Level Two Topic
- Level Two
- October 12, 2023
Bangla Translation.
Below is an example Patient Encounter Document based on the transcript you just heard:
Patient Encounter Document
Cardiologist: Dr. John Parker
Date: October 12, 2023
Patient: John Smith
DOB: July 8, 1957
Medical Record Number: 987654321
Chief Complaint: Mr. Smith presented with complaints of chest pain and associated symptoms.
History of Present Illness: Mr. Smith, a 66-year-old male, reported experiencing chest pain for the past several weeks. He described the pain as a squeezing sensation located in the center of his chest, radiating to the left arm, rated at 6-7/10 in intensity. The pain is typically triggered by physical activity, such as gardening or climbing stairs, and is associated with shortness of breath, dizziness, and occasional nausea.
Past Medical History:
1. Hypertension, treated with lisinopril.
2. Non-smoker.
3. Occasional alcohol consumption.
4. No known allergies to medications.
Family History: Father had a heart attack in his early 60s, and mother has a history of hypertension.
Medications:
1. Lisinopril for hypertension.
Assessment and Plan: Based on Mr. Smith’s presentation, risk factors, and physical examination, there is a concern for possible cardiac involvement. The following steps have been taken:
1. EKG: An EKG was performed, which showed ST-segment depression in leads II, III, and aVF. Cardiac enzymes were ordered and revealed elevated troponin levels.
2. Medication Adjustment: Mr. Smith will continue lisinopril for hypertension management.
3. Nitroglycerin: Nitroglycerin has been recommended for chest pain relief as needed, and proper instructions were provided.
4. Stress Test: A stress test is scheduled to assess cardiac function and exercise tolerance.
5. Cardiology Consultation: Mr. Smith will be referred to a cardiologist for further evaluation and consideration of coronary angiography.
Follow-up: Mr. Smith is scheduled for a stress test on XXXXXXXX. He is instructed to call 911 if he experiences severe chest pain before this appointment.
Scribe: [Name]
Supervisor: Dr. John Parker
