🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-07-30 05:03:11
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, presented with chest discomfort experienced after intense cardio workouts. He described the pain as sharp on the left side, lasting 5 to 10 minutes and resolving with rest. He mentioned feeling slightly out of breath at times but considered it normal.
Objective:
No specific objective findings provided in the transcription.
Assessment:
Possible musculoskeletal chest pain post intense cardio workouts. Differential includes cardiac etiology. To rule out cardiac concerns, plan for an ECG and a treadmill stress test. Advised the patient to avoid high-intensity intervals until test results are obtained.
Plan:
- Perform an ECG and a treadmill stress test to evaluate cardiac function.
- Instructed the patient to refrain from high-intensity intervals until further assessment.
- Follow-up scheduled post-test to review results and determine the next steps.