🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-30 11:45:40

Transcript

<thead>
                                                <tr>
                                                   <th>Original Transcription</th>
                                                </tr>
                                             </thead>
                                             <tbody><tr><td id="fragmentid_1"><div><p><strong>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>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>Doctor</strong>: Any shortness of breath, nausea, or palpitations?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>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>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>Patient</strong>: Okay, I'll scale back a bit.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong>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>Patient</strong>: Thank you, Dr.. I appreciate it.</p></div></td></tr></tbody>

Clinical Notes

SOAP Note

Subjective:

The patient, Omit, presented with chest discomfort 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.

Objective:

No specific objective findings were noted during the consultation.

Assessment:

Possible musculoskeletal chest pain post intense cardio workouts. Differential diagnosis includes cardiac etiology due to the nature of the symptoms.

Plan:

  1. Conduct an ECG and a treadmill stress test to rule out any cardiac issues.
  2. Advise the patient to avoid high-intensity intervals until test results are available.
  3. Follow up with the patient after the tests to discuss further management based on results.
⬅ Back to History