🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-31 12:54:24

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and where is the</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, it's just right over on the</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and when did this</p></div></td></tr><tr><td id="fragmentid_4"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, it started just 30 minutes ago.</div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and did it just come on randomly or were you doing something</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, I was just juggling the driveway</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and has that pain been getting</p></div></td></tr><tr><td id="fragmentid_8"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: over the last half an hour?</div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, no, it just came on suddenly and it's a,</p></div></td></tr><tr><td id="fragmentid_10"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Yeah, the pain has been there this whole time</div></td></tr><tr><td id="fragmentid_11"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: and it's gotten worse ever since it started.</div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and how</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Is it kind of like an aching pain or is it a sharp or tight tightness</p></div></td></tr><tr><td id="fragmentid_14"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: How would you describe it?</div></td></tr><tr><td id="fragmentid_15"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, it feels dull.</div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I feel like there's a lot of pressure on</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, and how do you rate the pain right now on a scale</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> 0 being the least amount of pain you felt</p></div></td></tr><tr><td id="fragmentid_19"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: 10 being the worst.</div></td></tr><tr><td id="fragmentid_20"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, uh, 7.</div></td></tr><tr><td id="fragmentid_21"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: D, 7, okay.</div></td></tr><tr><td id="fragmentid_22"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Have you had New York similar episodes</p></div></td></tr><tr><td id="fragmentid_23"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, no, I've never had</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and is the pain just staying in the region of the left chest area that you mentioned or is it traveling to</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, no, I'm kind of</p></div></td></tr><tr><td id="fragmentid_26"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> On the left side, D, okay, uh, is there anything that you do that makes the pain either get worse</p></div></td></tr><tr><td id="fragmentid_27"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, uh, I think it's a bit bit worse if I'm moving around or when</p></div></td></tr><tr><td id="fragmentid_28"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I think it made it a bit worse, but nothing has seemed to make it any better</p></div></td></tr><tr><td id="fragmentid_29"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and does it change at all from you changing positions like if you're standing up</p></div></td></tr><tr><td id="fragmentid_30"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, I think it's a little bit worse when I'm laying</p></div></td></tr><tr><td id="fragmentid_31"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and other than the</p></div></td></tr><tr><td id="fragmentid_32"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> have you been having any other symptoms like a cough or difficulty breathing or any pain when</p></div></td></tr><tr><td id="fragmentid_33"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, uh, I felt a little bit assured of breath or having difficulty breathing since yesterday when the sorry since the</p></div></td></tr><tr><td id="fragmentid_34"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: but adjust the difficulty breathing.</div></td></tr><tr><td id="fragmentid_35"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and have you recently injured</p></div></td></tr><tr><td id="fragmentid_36"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Like from a fall or anything like that?</div></td></tr><tr><td id="fragmentid_37"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I do I play rugby and was tackled by another player</p></div></td></tr><tr><td id="fragmentid_38"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: But but my chest felt fine after that.</div></td></tr><tr><td id="fragmentid_39"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay so but the pain just started half an</p></div></td></tr><tr><td id="fragmentid_40"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, yeah.</div></td></tr><tr><td id="fragmentid_41"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, have you been</p></div></td></tr><tr><td id="fragmentid_42"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no, been at home.</div></td></tr><tr><td id="fragmentid_43"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, has anyone around you been</p></div></td></tr><tr><td id="fragmentid_44"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no.</div></td></tr><tr><td id="fragmentid_45"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> okay, have you been having any symptoms like nausea or vomiting or</p></div></td></tr><tr><td id="fragmentid_46"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, no nausea or vomiting, but I do</p></div></td></tr><tr><td id="fragmentid_47"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, but have you measured your temperature</p></div></td></tr><tr><td id="fragmentid_48"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, but I did and it was 38 degrees.</div></td></tr><tr><td id="fragmentid_49"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and have you been having any kind of</p></div></td></tr><tr><td id="fragmentid_50"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no swelling in my legs.</div></td></tr><tr><td id="fragmentid_51"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, have you been feeling tired at all,</p></div></td></tr><tr><td id="fragmentid_52"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no, my energy has been good.</div></td></tr><tr><td id="fragmentid_53"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, have you been having any kind of thumping or palpitations or feel like your heart has been</p></div></td></tr><tr><td id="fragmentid_54"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, it all hit does feel like it's beating faster right</p></div></td></tr><tr><td id="fragmentid_55"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> It usually only feels</p></div></td></tr><tr><td id="fragmentid_56"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and have you noticed any</p></div></td></tr><tr><td id="fragmentid_57"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Any rashes?</div></td></tr><tr><td id="fragmentid_58"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no rashes.</div></td></tr><tr><td id="fragmentid_59"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, have you had any cough or runny nose</p></div></td></tr><tr><td id="fragmentid_60"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Any kind of those symptoms and in the past</p></div></td></tr><tr><td id="fragmentid_61"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, a few weeks ago I was a little runny, but that went</p></div></td></tr><tr><td id="fragmentid_62"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: I haven't had any cough.</div></td></tr><tr><td id="fragmentid_63"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and have you been feeling dizzy at all or</p></div></td></tr><tr><td id="fragmentid_64"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, no dizziness and unknown</p></div></td></tr><tr><td id="fragmentid_65"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, just</p></div></td></tr><tr><td id="fragmentid_66"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Have you had any diagnosis made by any physician or anything like diabetes or high blood</p></div></td></tr><tr><td id="fragmentid_67"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, yeah, I've been told I have high cholesterol and high</p></div></td></tr><tr><td id="fragmentid_68"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> okay, and do you take any medications</p></div></td></tr><tr><td id="fragmentid_69"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, um, I do take medications for both blood</p></div></td></tr><tr><td id="fragmentid_70"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> rosyavastatin, and umlisynapril and I take a</p></div></td></tr><tr><td id="fragmentid_71"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and do you have any allergies to any</p></div></td></tr><tr><td id="fragmentid_72"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no allergies.</div></td></tr><tr><td id="fragmentid_73"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, have you had all in the past been hospitalized</p></div></td></tr><tr><td id="fragmentid_74"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no hospitalizations.</div></td></tr><tr><td id="fragmentid_75"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: D, any previous surgeries?</div></td></tr><tr><td id="fragmentid_76"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no.</div></td></tr><tr><td id="fragmentid_77"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and within your family has anyone passed away from a heart attack or any</p></div></td></tr><tr><td id="fragmentid_78"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no.</div></td></tr><tr><td id="fragmentid_79"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and currently right now,</p></div></td></tr><tr><td id="fragmentid_80"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Do you live with someone?</div></td></tr><tr><td id="fragmentid_81"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> And where do you live, like an</p></div></td></tr><tr><td id="fragmentid_82"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, I live in a house with um,</p></div></td></tr><tr><td id="fragmentid_83"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and do</p></div></td></tr><tr><td id="fragmentid_84"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, yeah, I drive a</p></div></td></tr><tr><td id="fragmentid_85"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: D, okay, and in your daily routine,</div></td></tr><tr><td id="fragmentid_86"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> would you say you get enough exercise throughout</p></div></td></tr><tr><td id="fragmentid_87"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, yeah, usually on Sundays</p></div></td></tr><tr><td id="fragmentid_88"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: D, okay, and how about your diet?</div></td></tr><tr><td id="fragmentid_89"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Well, how's your diet like,</p></div></td></tr><tr><td id="fragmentid_90"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, um, usually I feel like it's fairly</p></div></td></tr><tr><td id="fragmentid_91"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I might I eat out a little bit too often, but try to eat as many vegetables</p></div></td></tr><tr><td id="fragmentid_92"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and</p></div></td></tr><tr><td id="fragmentid_93"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, I do yes.</div></td></tr><tr><td id="fragmentid_94"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Been smoking for the last 20 years</p></div></td></tr><tr><td id="fragmentid_95"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, how much do you smoke</p></div></td></tr><tr><td id="fragmentid_96"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, about a half a pack to a pack a</p></div></td></tr><tr><td id="fragmentid_97"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: D, okay, and do you drink?</div></td></tr><tr><td id="fragmentid_98"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no alcohol.</div></td></tr><tr><td id="fragmentid_99"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and any recreational</p></div></td></tr><tr><td id="fragmentid_100"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, um, no marijuana, but I have used</p></div></td></tr><tr><td id="fragmentid_101"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and when was the last time that</p></div></td></tr><tr><td id="fragmentid_102"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, um, six days ago.</div></td></tr><tr><td id="fragmentid_103"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, six days ago, okay, and how often do you</p></div></td></tr><tr><td id="fragmentid_104"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, um, I would say a couple</p></div></td></tr><tr><td id="fragmentid_105"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, a couple of times a month,</p></div></td></tr><tr><td id="fragmentid_106"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> All right, and for how long have you been using</p></div></td></tr><tr><td id="fragmentid_107"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, up for the last seven years.</div></td></tr><tr><td id="fragmentid_108"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: D, seven years, okay.</div></td></tr></tbody>

Clinical Notes

SOAP Note

Subjective

The patient reports sudden onset chest pain that feels dull with a pressure sensation. The pain started 30 minutes ago while juggling in the driveway and has worsened since onset. The current pain level is rated as 7 out of 10. The patient denies similar previous episodes, radiation of pain, but mentions worsening with movement. There is associated shortness of breath since yesterday. The patient has a history of high cholesterol and high blood pressure, takes rosuvastatin and lisinopril, and reports no allergies. The patient smokes half a pack to a pack of cigarettes daily for the last 20 years.

Objective

  • Chest pain described as dull with pressure sensation, rated 7/10.
  • Shortness of breath since yesterday.
  • Temperature measured at 38 degrees.
  • History of high cholesterol and high blood pressure.
  • Takes rosuvastatin and lisinopril.
  • Smoking half a pack to a pack of cigarettes daily for the last 20 years.

Assessment

  1. Acute chest pain - Differential diagnosis includes musculoskeletal pain, cardiac etiology, or respiratory cause.
  2. Shortness of breath - Likely related to chest pain, further evaluation needed.
  3. High cholesterol and high blood pressure - Known medical history, currently on rosuvastatin and lisinopril.
  4. Smoking history - Significant risk factor for cardiovascular and respiratory conditions.

Plan

  1. Conduct further evaluation to determine the cause of chest pain and shortness of breath.
  2. Consider ECG, chest X-ray, and cardiac enzymes to rule out cardiac causes.
  3. Advise smoking cessation and provide resources for smoking cessation programs.
  4. Monitor vital signs and symptoms closely.
  5. Follow up with the patient for review of diagnostic tests and adjustment of treatment plan as needed.
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