🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-31 09:12:59

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 for about three weeks, especially after physical activities like climbing stairs or walking briskly. Describes the sensation as uncomfortable, not sharp pain.

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

  • Associated Symptoms: Experiences quick shortness of breath, occasional lightheadedness.

  • 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. Increased due to personal history of high blood pressure and family history of heart disease.

Plan

  1. Diagnostics:

  2. Order ECG, echocardiogram, and stress test to evaluate heart function and blood flow.

  3. Treatment:

  4. Depending on test results, may require medication and lifestyle modifications.

  5. Lifestyle Recommendations:

  6. Advise heart-healthy diet, light regular exercise, stress management techniques, and medication adherence.
  7. Emphasize the importance of avoiding heavy exertion.

  8. Encourage improvement in diet and activity levels.

  9. Follow-Up:

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