🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-31 12:38:12

Transcript

[00:00 → 00:05] Stethoscope emoji, Dr. Patient Conversation, Cardiovascular Concern
[00:05 → 00:13] Patient, Good Morning, Dr. I've been feeling a strange tightness in my chest lately, especially
[00:13 → 00:19] after climbing stairs or walking briskly. It's not sharp pain, but it's uncomfortable.
[00:19 → 00:26] Dr. Good Morning. I'm glad you came in. Chest tightness can be an early sign of several
[00:26 → 00:32] conditions, including cardiovascular issues. How long has this been happening?
[00:32 → 00:37] Patient, for about three weeks now. At first, I thought it was stress or fatigue, but
[00:37 → 00:43] it's happening more often now. Dr., is the tightness located in the center
[00:43 → 00:49] of your chest or on one side? Patient, mostly in the center. It usually goes away
[00:49 → 00:54] after a few minutes of rest. Dr., that could be angina, which is due
[00:54 → 01:00] to reduced blood flow to the heart. Any shortness of breath, nausea, or dizziness?
[01:00 → 01:06] Patient, yes, I do get winded quickly and sometimes feel light-headed.
[01:06 → 01:12] Dr., do you have any medical history, like high blood pressure, diabetes, or a family
[01:12 → 01:17] history of heart disease? Patient, I have high blood pressure and my
[01:17 → 01:24] father had a heart attack in his early fifties. Dr., that increases your risk. We'll need
[01:24 → 01:31] to perform an ECG, echocardiogram, and a stress test. These will give us insights into your
[01:31 → 01:39] heart's performance. Patient, is it serious? Dr, it could be. But the good news is, early
[01:39 → 01:44] diagnosis leads to better outcomes. Depending on the results, we might need medication
[01:44 → 01:50] or lifestyle changes. Patient, what kind of lifestyle changes?
[01:50 → 01:58] Dr, a heart-healthy diet, regular light exercise, stress management, and medication compliance.
[01:58 → 02:04] Also, no smoking if applicable. Patient, I don't smoke. But I do need to improve
[02:04 → 02:11] my diet and activity levels. Dr, that's a good start. We'll schedule the tests and review
[02:11 → 02:16] everything together. In the meantime, avoid heavy exertion.
[02:16 → 02:23] Patient, thank you, doctor. I appreciate the care. Doctor, you're welcome. We'll take
[02:23 → 02:24] good care of you.

Clinical Notes

Subjective

  • Patient: Reports feeling a strange tightness in the chest, especially after physical activity like climbing stairs or walking briskly. Describes it as uncomfortable, not sharp pain, occurring for about three weeks, initially thought to be stress or fatigue.

  • Location of Tightness: Mostly in the center of the chest, usually resolves after a few minutes of rest.

  • Associated Symptoms: Reports getting winded quickly, feeling light-headed.

  • Medical History:

  • High blood pressure.
  • Family history of heart disease (father had a heart attack in his early fifties).

Objective

  • No specific objective data provided.

Assessment

  1. Angina: Suspected due to chest tightness, especially with physical exertion, and associated symptoms like shortness of breath and lightheadedness.

  2. Cardiovascular Risk:

  3. Patient's history of high blood pressure and family history of heart disease increase the risk of cardiovascular issues.

Plan

  1. Diagnostics:

  2. Order an ECG, echocardiogram, and stress test to evaluate heart function and assess for any underlying cardiovascular conditions.

  3. Lifestyle Modifications:

  4. Advise a heart-healthy diet.
  5. Recommend regular light exercise.
  6. Stress management techniques.
  7. Emphasize medication compliance.

  8. Encourage to avoid heavy exertion until further evaluation.

  9. Follow-Up:

  10. Schedule a follow-up to review test results and discuss further management based on the findings.
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