🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-07-30 06:51:01
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>
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, especially after physical activity, lasting for about three weeks."
History of Present Illness (HPI): - Onset: Three weeks ago - Duration: Continuous - Location: Center of the chest - Quality: Not sharp, uncomfortable - Associated Symptoms: Shortness of breath, feeling light-headed - Aggravating/Relieving Factors: Relieved by rest
Assessment: - Primary Diagnosis: Angina (suspected)
Plan: - Referral for further cardiac evaluation - Follow-up in one week for symptom review and assessment of diagnostic tests.