🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-26 12:33:28

Transcript

Doctor: Hi, Omit. I see you've come in with some chest discomfort after your gym workouts. Can you describe what you're feeling?

Patient: Hi, Doctor. It's a sharp pain on the left side that comes after intense cardio. It lasts about 5-10 minutes and goes away if I rest.

Doctor: Any Shortness of Breath, Nausea, or Palpitations?

Patient: Sometimes I feel a little out of breath, but I thought it was normal.

Doctor: 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.

Patient: Okay, I'll scale back a bit.

Doctor: Good. We'll follow up after the test. It's always better to be safe, especially with chest symptoms.

Patient: Thank you, Doctor. I appreciate it.

Clinical Notes

Subjective

  • Patient: Omit.

  • Primary Concern: Presenting with sharp left-sided chest pain following intense cardio workouts lasting 5-10 minutes, relieved by rest.

  • Associated Symptoms:

    • Reports occasional shortness of breath during episodes of chest discomfort.

Objective

  • No relevant data.

Assessment

  1. Chest Pain:
    • Differential includes musculoskeletal etiology; however, cardiac origin needs to be ruled out due to the nature of symptoms.

Plan

  1. Diagnostics:

    • Order an ECG and a treadmill stress test to evaluate cardiac function and rule out any underlying cardiac issues.

  2. Activity Modification:

    • Advise the patient to avoid high-intensity intervals until further evaluation to prevent exacerbation of symptoms.

  3. Follow-Up:

    • Schedule a follow-up appointment after the tests to review results and determine the next steps for management.
⬅ Back to History