🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-30 09:08:02

Transcript

<thead>
                                                <tr>
                                                   <th>Original Transcription</th>
                                                </tr>
                                             </thead>
                                             <tbody><tr><td id="fragmentid_1"><div><p><strong>Patient</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong>Doctor</strong>: 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?</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong>Patient</strong>: For about three weeks now. At first, I thought it was stress or fatigue, but it's happening more often now.</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>Doctor</strong>: Is the tightness located in the center of your chest or on one side?</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong>Patient</strong>: Mostly in the center. It usually goes away after a few minutes of rest.</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong>Doctor</strong>: That could be angina, which is due to reduced blood flow to the heart. Any shortness of breath, nausea, or dizziness?</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong>Patient</strong>: Yes, I do get winded quickly and sometimes feel light-headed.</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong>Doctor</strong>: Do you have any medical history, like high blood pressure, diabetes, or a family history of heart disease?</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong>Patient</strong>: I have high blood pressure and my father had a heart attack in his early 50s.</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong>Doctor</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong>Patient</strong>: Is it serious?</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong>Doctor</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong>Patient</strong>: What kind of lifestyle changes?</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong>Doctor</strong>: A heart-healthy diet, regular light exercise, stress management, and medication compliance. Also, no smoking if applicable.</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong>Patient</strong>: I don't smoke. But I do need to improve my diet and activity levels.</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong>Doctor</strong>: That's a good start. We'll schedule the tests and review everything together. In the meantime, avoid heavy exertion.</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong>Patient</strong>: Thank you, Dr.. I appreciate the care.</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong>Doctor</strong>: You're welcome. We'll take good care of you.</p></div></td></tr></tbody>

Clinical Notes

Patient Information

  • Patient Name: Not provided
  • Age / DOB: Not provided
  • Gender: Not provided
  • Contact Number: Not provided
  • Date of Visit: Not provided

Chief Complaint / Reason for Visit

The patient reports feeling a strange tightness in the chest, especially after physical activities like climbing stairs or walking briskly. The discomfort is not sharp but persistent, worsening over the past three weeks.

Medical History

  • Chronic Illnesses:
  • High blood pressure
  • Family History:
  • Father had a heart attack in his early 50s

Vital Signs

  • Blood Pressure: Not documented
  • Pulse Rate: Not documented
  • Temperature: Not documented
  • Respiratory Rate: Not documented
  • Oxygen Saturation (SpO2): Not documented
  • Weight: Not documented
  • Height: Not documented
  • BMI: Not documented

General Physical Examination

  • Appearance: Not documented
  • Cardiovascular: Reports chest tightness, shortness of breath, and lightheadedness
  • Neurological: Not documented

Assessment / Diagnosis

The patient's symptoms of chest tightness, especially with exertion, along with a family history of heart disease and high blood pressure, raise concerns for angina. Further investigations are needed to confirm the diagnosis.

Plan

  1. Perform the following tests:
  2. ECG
  3. Echocardiogram
  4. Stress test
  5. Emphasize lifestyle modifications:
  6. Heart-healthy diet
  7. Regular light exercise
  8. Stress management
  9. Medication compliance
  10. Smoking cessation (if applicable)
  11. Advise the patient to avoid heavy exertion until further evaluation.
  12. Schedule a follow-up to review test results and discuss further management.
⬅ Back to History