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Voice-to-Documentation Studio

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James Wilson

43M • MRN: 29384756 • Visit: Follow-up • Provider: Dr. Rebecca Chen

Session Duration

08:42

Real-time Transcription

Live
Dr. Chen:

Good morning, James. How have you been feeling since our last visit?

Patient:

Morning, doc. I've been doing mostly okay. The chest pain I was having has gotten better since you changed my medication. I'm not feeling it as often.

Dr. Chen:

That's good to hear. So the Metoprolol is helping with the chest discomfort? Any side effects you've noticed?

Patient:

I did feel a bit tired the first few days, but that's gotten better. I've been checking my blood pressure at home like you suggested, and it's been around 130/85 most days.

Dr. Chen:

Those blood pressure numbers are better than before, but still a bit higher than our target. How about your exercise routine? Have you been able to keep up with the walking program?

Patient:

Honestly, I haven't been as consistent as I should be. I managed about 20 minutes three times a week, but work has been really busy. I did notice some swelling in my ankles at the end of the day, especially after I've been sitting at my desk for a long time.

Dr. Chen:

I see. The ankle swelling is something we should monitor. It could be related to your hypertension or might be a side effect of your medication. Let's check your legs today. Have you made any changes to your diet like we discussed?

Patient:

I've been trying to cut down on salt. My wife has been helping with that. I'm eating more vegetables and fruits too. I've cut back on alcohol as well, maybe one beer on weekends instead of the couple I used to have almost every night...

AI Entity Recognition

Real-time

Symptoms

  • Chest pain Improving
  • Ankle swelling New
  • Fatigue Transient

Medications

  • Metoprolol Current

Vitals & Measurements

  • Blood pressure 130/85

Diagnoses

  • Hypertension Ongoing

Lifestyle & Habits

  • Exercise 20min × 3/week
  • Diet Reduced salt
  • Alcohol Reduced

Auto-Generated Note

Auto-updating

SOAP Note

Follow-up Visit • 04/20/2025 • Dr. Rebecca Chen

SUBJECTIVE:

43-year-old male presents for follow-up of hypertension. Patient reports improvement in chest pain since starting Metoprolol. He reports home blood pressure readings averaging 130/85. Patient notes transient fatigue when starting medication that has since improved. New complaint of ankle swelling at the end of the day, especially after prolonged sitting.

Exercise & Lifestyle:

Patient reports exercising approximately 20 minutes, three times weekly, less than recommended frequency. Diet changes include reduced salt intake, increased consumption of fruits and vegetables. Alcohol consumption reduced to occasional use (one beer on weekends vs. previous daily intake).

OBJECTIVE:
Generating as visit continues...
ASSESSMENT:
  1. Hypertension (I10): Improved but not at target. Home readings averaging 130/85.
  2. Chest pain: Improved since starting beta-blocker.
  3. Peripheral edema: New finding, possibly related to hypertension or medication.
PLAN:
  1. Continue Metoprolol with possible dosage adjustment pending physical exam.
  2. Evaluate peripheral edema.
  3. Reinforce exercise recommendations - target 30 minutes 5x weekly.
  4. Continue dietary modifications with reduced sodium.
  5. Follow-up in 1 month with home BP log.

AI Clinical Insights & Suggestions

Documentation Suggestions

  • Consider documenting characteristics of ankle edema (pitting/non-pitting, timing, severity)
  • Include specific values from home BP monitoring log
  • Document frequency and character of chest pain episodes

Clinical Decision Support

  • Consider screening ECG due to history of chest pain
  • Check basic metabolic panel due to new edema and Metoprolol use
  • Consider medication adjustment if edema is related to Metoprolol

Knowledge Graph Updates

  • Adding "peripheral edema" to active problem list
  • Updating medication response for Metoprolol: partial improvement of chest pain
  • Associating patient's hypertension with potential compliance concerns
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