🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-07-29 06:11:37
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>Patient: Is it serious?<br><br>Doctor: It could be. But the good news is, early diagnosis leads to better outcomes. Depending on the results, we might need medication or lifestyle changes.<br><br>Patient: What kind of lifestyle changes?<br><br>Doctor: A heart-healthy diet, regular light exercise, stress management, and medication compliance. Also, no smoking if applicable.<br><br>Patient: I don't smoke. But I do need to improve my diet and activity levels.<br><br>Doctor: That's a good start. We'll schedule the tests and review everything together. In the meantime, avoid heavy exertion.<br><br>Patient: Thank you, Dr.. I appreciate the care.<br><br>Doctor: You're welcome. We'll take good care of you.<br><br>
Clinical Notes
SOAP Note
- Subjective:
- The patient reports feeling a strange tightness in the center of the chest for about three weeks, especially after physical activities like climbing stairs or walking briskly. Initially thought to be stress or fatigue-related, the frequency of occurrence has increased. The patient also experiences quick shortness of breath and occasional lightheadedness.
-
Past medical history includes high blood pressure, and there is a family history of heart disease, with the patient's father having a heart attack in his early 50s.
-
Objective:
-
No specific objective findings provided in the transcription.
-
Assessment:
- Suspected angina due to chest tightness, possibly related to reduced blood flow to the heart.
-
Increased risk of cardiovascular issues due to a family history of heart disease and personal history of high blood pressure.
-
Plan:
- Further diagnostic tests recommended:
- ECG
- Echocardiogram
- Stress test
- Lifestyle modifications advised:
- Heart-healthy diet
- Regular light exercise
- Stress management
- Medication compliance
- Smoking cessation (if applicable)
- Emphasized the importance of early diagnosis for better outcomes.
- Instructed the patient to avoid heavy exertion until further evaluation.
- Follow-up planned to review test results and discuss treatment options.