🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-07-30 05:10:37
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. The pain is described as sharp, located on the left side, lasting 5 to 10 minutes, and relieved by rest. The patient also mentioned feeling slightly out of breath at times.
Objective:
- No objective findings provided in the transcription.
Assessment:
Possible musculoskeletal chest pain post intense cardio workouts. Differential includes cardiac etiology, warranting further investigation to rule out cardiac issues.
Plan:
- Conduct an ECG and a treadmill stress test to evaluate cardiac function.
- Advise the patient to avoid high-intensity intervals until test results are available.
- Follow up with the patient after the tests to review the findings.
- Emphasize the importance of caution with chest symptoms and the need for appropriate evaluation.
- Patient advised to scale back workout intensity for the time being.