🩺 Record Detail
Patient Info
Transcript
Patient: 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.<br><br>Doctor: 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?<br><br>Patient: For about three weeks now. At first, I thought it was stress or fatigue, but it's happening more often now.<br><br>Doctor: Is the tightness located in the center of your chest or on one side?<br><br>Patient: Mostly in the center. It usually goes away after a few minutes of rest.<br><br>Doctor: That could be angina, which is due to reduced blood flow to the heart. Any shortness of breath, nausea, or dizziness?<br><br>Patient: Yes, I do get winded quickly and sometimes feel light-headed.<br><br>Doctor: Do you have any medical history, like high blood pressure, diabetes, or a family history of heart disease?<br><br>Patient: I have high blood pressure and my father had a heart attack in his early 50s.<br><br>Doctor: That increases your risk. We'll need to perform an ECG, echocardiogram, and a stress test. These will give us insights into your heart's performance.<br><br>
Clinical Notes
Patient Information • Patient Name: • Date of Birth: • Date of Visit: • Gender: • Patient ID:
Chief Complaint (CC): "Patient reports feeling a strange tightness in the chest, especially after physical activity, for the past three weeks."
History of Present Illness (HPI): • Onset: Three weeks ago • Duration: Persistent • Location: Center of the chest • Quality: Not sharp, uncomfortable • Associated Symptoms: Shortness of breath, light-headedness • Aggravating/Relieving Factors: Relieved by rest
Past Medical History (PMH): • Hypertension • Family history of heart disease (father had a heart attack in his early 50s)
Review of Systems (ROS): • Cardiovascular: Chest tightness, shortness of breath
Physical Examination (PE): • General Appearance: Well-appearing • Cardiovascular: To be assessed
Assessment: • Primary Diagnosis: Angina • Secondary Diagnosis: Hypertension
Plan: • Investigations: ECG, echocardiogram, stress test • Referral: Cardiologist for further evaluation • Follow-Up: Await results for further management decisions.