🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-02 06:58:49

Transcript

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                                                   <th><strong>Original Transcription</strong></th>
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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">Doctor</strong>: Hi, Omit. I see you've come in with some chest discomfort after your gym workouts. Can you describe what you're feeling?</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="Patient">Patient</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="Doctor">Doctor</strong>: Any shortness of breath, nausea, or palpitations?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="Patient">Patient</strong>: Sometimes I feel a little out of breath, but I thought it was normal.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="Doctor">Doctor</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="Patient">Patient</strong>: Okay, I'll scale back a bit.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="Doctor">Doctor</strong>: Good. We'll follow up after the test. It's always better to be safe, especially with chest symptoms.</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="Patient">Patient</strong>: Thank you, Dr.. I appreciate it.</p></div></td></tr></tbody>

Clinical Notes

SOAP Note

  • Subjective:

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

  • Objective:

  • No specific objective findings mentioned in the provided transcription.

  • Assessment:

  • Differential Diagnosis:
    • Musculoskeletal chest pain.
    • Cardiac origin chest pain.

  • Plan:

    • Order an ECG and a treadmill stress test to rule out cardiac issues.
    • Advise the patient to avoid high-intensity intervals until test results are obtained.

  • Plan:

  • Instruct the patient to scale back on workout intensity.
  • Schedule a follow-up appointment post-test to review the results and determine further management.
  • Emphasize the importance of caution with chest symptoms and the need for evaluation to ensure safety.
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