🩺 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>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
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 for about three weeks, especially after physical activity like climbing stairs or walking briskly. Describes it as uncomfortable, not sharp pain."
History of Present Illness (HPI): • Onset: Three weeks ago • Duration: Persistent • Location: Mostly in the center of the chest • Quality: Tightness • Associated Symptoms: Shortness of breath, feeling light-headed • 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)
Social History: • Non-smoker
Physical Examination (PE): • General Appearance: Not documented • Cardiovascular: Chest tightness, no other abnormalities noted
Assessment: • Primary Diagnosis: Angina (suspected) due to chest tightness, associated with shortness of breath and lightheadedness • Secondary Diagnosis: Hypertension
Plan: • Investigations: ECG, echocardiogram, stress test • Lifestyle Changes: Heart-healthy diet, light exercise, stress management, medication compliance • Follow-Up: Review test results together, avoid heavy exertion, schedule follow-up visit for further management