🩺 Record Detail

Patient Info

Name: Anoj
Age: 52 years
Date: 2025-07-21 04:44:41

Transcript

[00:00 → 00:09] Hi Dr. My name is Anoj and I am facing chest pain for the last days.
[00:09 → 00:15] In my appetite is very less and I am not able to eat, but there is nausea and other
[00:15 → 00:16] feelings.
[00:16 → 00:24] I am 52 and I have a lot of pressure, no empty life and I have been underpunged.

Clinical Notes

Subjective

  • Patient: Anoj, 52 years old.

  • Primary Concern: Chest pain for the last few days, decreased appetite, nausea, and other associated feelings.

  • Psychosocial Factors:

  • Reports feeling a lot of pressure.
  • Describes life as empty.
  • Mentions being under emotional stress.

Objective

  • No relevant data available

Assessment

  1. Acute Chest Pain: Presenting with chest pain, decreased appetite, and nausea, suggestive of a possible underlying condition.

  2. Psychosocial Stress: Reports feeling a lot of pressure, describing life as empty, and being under emotional stress.

Plan

  1. Immediate Evaluation:
  2. Conduct a thorough physical examination to assess the chest pain and associated symptoms.

  3. Consider an ECG to rule out any acute cardiac issues.

  4. Psychosocial Support:

  5. Discuss stress management techniques.

  6. Consider referral to a counselor or therapist for emotional support.

  7. Follow-Up:

  8. Schedule a follow-up appointment to review evaluation results and adjust the management plan accordingly.
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