🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-30 11:51:05

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

SOAP Note

  • Subjective:

  • Patient, Omit, presents with chest discomfort occurring after intense cardio workouts. Describes the pain as sharp on the left side, lasting 5 to 10 minutes, and resolving with rest. Reports occasional feelings of being out of breath during exercise.

  • Objective:

  • No objective findings provided in the transcription.

  • Assessment:

  • Suspected musculoskeletal chest pain exacerbated by intense cardio workouts. Differential diagnosis includes cardiac etiology.

  • Plan:

  • Order an ECG and a treadmill stress test to rule out cardiac involvement.
  • Advise the patient to avoid high-intensity intervals until test results are available.
  • Follow up with the patient after the tests to discuss further management based on results.
  • Emphasize the importance of caution with chest symptoms and the need for proper evaluation.
  • Patient to scale back on exercise intensity as a precautionary measure.
  • Reiterate the significance of safety in managing chest symptoms.
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