🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-08-01 04:40:53
Transcript
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<tbody><tr><td id="fragmentid_1"><div><p><strong>Patient</strong>: Good Morning, Dr. I've been feeling a strange tightness in my chest lately, especially after climbing stairs or walking briskly. It's not sharp pain, but it's uncomfortable.</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong>Doctor</strong>: Good Morning. I'm glad you came in. Chest tightness can be an early sign of several conditions, including cardiovascular issues. How long has this been happening?</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> after climbing stairs or walking briskly. It's not sharp pain, but it's</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Dr. Good Morning. I'm glad you came in. Chest tightness can be an</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> conditions, including cardiovascular How long has this</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Patient, for about three weeks now. At first, I thought it was stress or fatigue,</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> happening more often now. Dr., is the tightness located in the center of</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> one side? Patient, mostly in the center. It usually goes away after a few</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Dr., that could be angina, which is due to reduced blood flow to the heart. Any shortness</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> breath, nausea, or dizziness? Patient, yes, I do get winded quickly and sometimes</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Dr., do you have any medical history, like high blood pressure, diabetes, or a</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> history of heart disease? Patient, I have high blood pressure and my father</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> in his early 50s. Dr., that increases your risk. We'll need to perform an ECG,</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> and a stress test. These will give us insights into your</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Patient, is it serious? Dr., it could be. But the good news is, early diagnosis</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> outcomes. Depending on the results, we might need medication or lifestyle</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Patient, what kind of lifestyle changes? Dr., a heart -healthy diet,</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> stress management, and medication compliance. Also, no smoking if applicable.</p></div></td></tr></tbody>
Clinical Notes
SOAP Note
Subjective:
The patient reports feeling a strange tightness in the chest for about three weeks, especially after physical activities like climbing stairs or walking briskly. Initially thought to be stress or fatigue-related, the tightness is now occurring more frequently. The discomfort is mostly centralized and usually resolves after a few moments. The patient also experiences quick shortness of breath and sometimes feels winded. The patient has a history of high blood pressure, and the father had heart disease in his early 50s.
Objective:
- No specific objective data provided in the transcription.
Assessment:
- Differential diagnosis includes angina due to reduced blood flow to the heart, considering the patient's symptoms of chest tightness, shortness of breath, and quick fatigue.
- Increased risk due to a family history of heart disease and personal history of high blood pressure.
- Further evaluation needed with an ECG and stress test to determine the underlying cause of symptoms and assess cardiovascular health.
Plan:
- Order an ECG and stress test to gain insights into the patient's cardiovascular status.
- Emphasize the importance of early diagnosis for better outcomes.
- Discuss potential treatment options based on test results, which may include medication and lifestyle modifications.
- Recommend heart-healthy diet, stress management techniques, medication adherence, and smoking cessation if applicable.