🩺 Record Detail
Patient Info
Transcript
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<tbody><tr><td id="fragmentid_1"><div><p><strong>Doctor</strong>: Hi, Omit. I see you've come in with some chest discomfort after your gym workouts. Can you describe what you're feeling?</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong>Patient</strong>: Hi, Doctor. It's a sharp pain on the left side that comes after intense cardio. It lasts about 5 to 10 minutes and goes away if I rest.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong>Doctor</strong>: Any shortness of breath, nausea, or palpitations?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>Patient</strong>: Sometimes I feel a little out of breath, but I thought it was normal.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong>Doctor</strong>: It could be musculoskeletal, but I want to rule out anything cardiac. We'll start with an ECG and a treadmill stress test. Also, try avoiding high intensity intervals until we get the results.</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong>Patient</strong>: Okay, I'll scale back a bit.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong>Doctor</strong>: Good. We'll follow up after the test. It's always better to be safe, especially with chest symptoms.</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong>Patient</strong>: Thank you, Dr.. I appreciate it.</p></div></td></tr></tbody>
Clinical Notes
Patient Information: - Name: Omit - Age: Not specified - Sex: Not specified - Date of Birth: Not specified - Parent/Guardian Name: Not specified - Date of Consultation: Not specified - Referring Physician: Not specified
Chief Complaint: - Chest discomfort after intense cardio workouts
History of Present Illness (HPI): - Sharp pain on the left side lasting 5 to 10 minutes after intense cardio, relieved by rest - Occasionally feels a little out of breath
Assessment / Diagnosis: - Differential: Musculoskeletal vs. Cardiac etiology
Plan: - ECG and treadmill stress test to rule out cardiac issues - Avoid high-intensity intervals until test results are obtained - Follow-up after the tests
Additional Notes: - Patient agreed to scale back on exercise intensity - Emphasized importance of evaluating chest symptoms thoroughly