🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-30 05:08:00

Transcript

<div><b>Doctor</b>: Hi, Omit. I see you've come in with some chest discomfort after your gym workouts. Can you describe what you're feeling?</div><br><div><b>Patient</b>: Hi, Doctor. It's a sharp pain on the left side that comes after intense cardio. It lasts about 5 to 10 minutes and goes away if I rest.</div><br><div><b>Doctor</b>: Any shortness of breath, nausea, or palpitations?</div><br><div><b>Patient</b>: Sometimes I feel a little out of breath, but I thought it was normal.</div><br><div><b>Doctor</b>: It could be musculoskeletal, but I want to rule out anything cardiac. We'll start with an ECG and a treadmill stress test. Also, try avoiding high intensity intervals until we get the results.</div><br><div><b>Patient</b>: Okay, I'll scale back a bit.</div><br><div><b>Doctor</b>: Good. We'll follow up after the test. It's always better to be safe, especially with chest symptoms.</div><br><div><b>Patient</b>: Thank you, Dr.. I appreciate it.</div><br>

Clinical Notes

SOAP Note

Subjective:

The patient, Omit, presents with chest discomfort experienced after intense cardio workouts. The pain is described as sharp and located on the left side, lasting for about 5 to 10 minutes and resolving with rest. The patient also reports feeling slightly out of breath at times.

Objective:

No specific objective findings provided in the transcription.

Assessment:

  1. Chest discomfort possibly related to exercise, with symptoms suggestive of musculoskeletal origin.
  2. Differential diagnosis includes cardiac causes, warranting further investigation to rule out cardiac issues.

Plan:

  1. Perform an ECG and a treadmill stress test to evaluate cardiac function and rule out any cardiac abnormalities.
  2. Advise the patient to avoid high-intensity intervals until test results are available.
  3. Follow up with the patient after the tests to review the results and determine the next steps.
  4. Emphasize the importance of caution, especially concerning chest symptoms, to ensure patient safety.
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