🩺 Record Detail
Patient Info
Transcript
[00:00 → 00:04] D, okay, and where is the pain exactly? [00:04 → 00:08] P, it's just right over on the left side. [00:08 → 00:12] D, okay, and when did this pain start? [00:12 → 00:15] P, it started just 30 minutes ago. [00:15 → 00:21] D, okay, and did it just come on randomly or were you doing something strenuous? [00:21 → 00:25] P, I was just juggling the driveway and it came on. [00:25 → 00:29] D, okay, and has that pain been getting worse at all [00:29 → 00:31] over the last half an hour? [00:31 → 00:37] P, no, it just came on suddenly and it's a, uh, I'm sorry. [00:37 → 00:39] Yeah the pain has been there this whole time [00:39 → 00:42] and it's gotten worse ever since it started. [00:42 → 00:46] D, okay, and how would you describe the pain? [00:46 → 00:51] Is it kind of like an aching pain or is it a sharp or tight tightness kind of pain? [00:51 → 00:53] How would you describe it? [00:53 → 00:55] P, it feels dull. [00:55 → 00:59] I feel like there's a lot of pressure on my chest. [00:59 → 01:03] D, and how do you rate the pain right now on a scale of 0 to 10, [01:03 → 01:08] 0 being the least amount of pain you felt in your life, 10 being the worst? [01:08 → 01:11] P, uh, 7. [01:11 → 01:14] D, 7, okay. [01:14 → 01:17] Have you had New York similar episodes before? [01:17 → 01:22] P, no, I've never had any chest pain before. [01:22 → 01:30] D, okay, and is the pain just staying in the region of the left chest area that you mentioned or is it traveling to any other part of your body? [01:30 → 01:35] P, no, I'm kind of just feeling it right here. [01:35 → 01:37] On the left side. [01:37 → 01:44] D, okay, uh, is there anything that you do that makes the pain either get worse or go away or like get better? [01:44 → 01:51] P, uh, I think it's a bit bit worse if I'm moving around or when I was walking in here. [01:51 → 01:57] I think it made it a bit worse, but nothing has seemed to make it any better since it's starting. [01:57 → 02:05] D, okay, and does it change at all from you changing positions like if you're standing up versus sitting down or laying down? [02:05 → 02:09] P, I think it's a little bit worse when I'm laying down. [02:09 → 02:13] D, okay, and other than the pain that you've been having, [02:13 → 02:20] have you been having any other symptoms like a cough or difficulty breathing or any pain when you're breathing in or out? [02:20 → 02:30] P, uh, I felt a little bit assured of breath or having difficulty breathing since yesterday when the sorry since the pain started, but adjust the difficulty breathing. [02:30 → 02:36] D, okay, and have you recently injured your chest or surrounding area at all? [02:36 → 02:39] Like from a fall or anything like that? [02:39 → 02:44] P, I do I play rugby and was tackled by another player yesterday. [02:44 → 02:47] But but my chest felt fine after that. [02:48 → 02:52] D, okay so but the pain just started half an hour ago. [02:52 → 02:54] P, yeah. [02:54 → 02:59] D, okay, have you been traveling at all recently? [02:59 → 03:02] P, no, been at home. [03:02 → 03:06] D, okay, has anyone around you been sick at all? [03:06 → 03:08] P, no. [03:08 → 03:15] D, okay, have you been having any symptoms like nausea or vomiting or any fevers or chills? [03:15 → 03:20] P, no nausea or vomiting, but I do feel a little bit hot today. [03:20 → 03:24] D, okay, but have you measured your temperature at all? [03:24 → 03:28] P, but I did and it was 38 degrees. [03:28 → 03:34] D, okay, and have you been having any kind of swelling in your legs or feet? [03:34 → 03:37] P, uh, no swelling in my legs. [03:37 → 03:39] D, okay. [03:39 → 03:44] Have you been feeling tired at all, like increasingly fatigued? [03:44 → 03:46] P, no. [03:46 → 03:48] My energy has been good. [03:48 → 03:55] D, have you been having any kind of thumping or palpitations or feel like your heart has been racing at all? [03:55 → 03:59] P, it all hit does feel like it's beating faster right now. [03:59 → 04:03] It usually only feels like this when I'm playing sports. [04:03 → 04:05] D, okay. [04:05 → 04:08] And have you noticed any changes in your skin at all? [04:08 → 04:10] Any rashes? [04:10 → 04:12] P, no rashes. [04:12 → 04:14] D, okay. [04:14 → 04:17] Have you had any cough or runny nose or sore throat? [04:17 → 04:21] Any kind of those symptoms and in the past month? [04:21 → 04:26] P, a few weeks ago I was a little runny, but that went away on its own. [04:26 → 04:28] I haven't had any cough. [04:28 → 04:30] D, okay. [04:30 → 04:34] And have you been feeling dizzy at all or have you fainted? [04:34 → 04:38] P, no dizziness and unknown I haven't fainted at all. [04:38 → 04:40] D, okay. [04:40 → 04:42] Just a few more questions. [04:42 → 04:49] Have you had any diagnosis made by any physician or any anything like diabetes or high blood pressure? [04:49 → 04:51] P, yeah. [04:51 → 04:54] I've been told I have high cholesterol and high blood pressure. [04:54 → 04:56] D, okay. [04:56 → 04:59] And do you take any medications for these things? [04:59 → 05:01] P, um. [05:01 → 05:09] I do take medications for both blood pressure and cholesterol, rasiavastatin, and umlisynapril and I take a multivitamin. [05:09 → 05:11] D, okay. [05:11 → 05:15] And do you have any allergies to any medications at all? [05:15 → 05:17] P, no allergies. [05:17 → 05:19] D, okay. [05:19 → 05:23] Have you had all in the past been hospitalized for any reason? [05:23 → 05:26] P, no hospitalizations. [05:26 → 05:29] D, any previous surgeries. [05:29 → 05:31] P, no. [05:31 → 05:32] D, okay. [05:32 → 05:38] And within your family, has anyone passed away from a heart attack or any cancers that run in the family? [05:39 → 05:41] P, no. [05:41 → 05:42] D, okay. [05:42 → 05:46] And currently right now, do you live alone? [05:46 → 05:48] Do you live with someone? [05:48 → 05:51] And where do you live, like an apartment or house? [05:51 → 05:54] P, I live in a house with um. [05:54 → 05:56] My parents. [05:56 → 05:57] D, okay. [05:57 → 05:59] And do you currently work? [05:59 → 06:01] P, yeah. [06:01 → 06:03] I drive a bus for the city. [06:03 → 06:05] D, okay. [06:05 → 06:11] And in your daily routine, would you say you get enough exercise throughout the week? [06:11 → 06:13] P, oh yeah. [06:13 → 06:15] Usually on Sundays I'll go for a run. [06:15 → 06:17] D, okay. [06:17 → 06:19] And how about your diet? [06:19 → 06:23] Well, how's your diet like, just regularly? [06:23 → 06:25] P, um. [06:25 → 06:28] Usually I feel like it's fairly balanced overall. [06:28 → 06:34] I might I eat out a little bit too often, but try to eat as many vegetables as I can. [06:34 → 06:36] D, okay. [06:36 → 06:39] And do you smoke cigarettes at all? [06:39 → 06:41] P, I do yes. [06:41 → 06:44] Been smoking for the last 20 years roughly. [06:44 → 06:46] D, okay. [06:46 → 06:49] How much do you smoke on an average day? [06:49 → 06:52] P, about a half a pack to a pack a day. [06:52 → 06:54] D, okay. [06:54 → 06:56] And do you drink? [06:56 → 06:58] P, no alcohol. [06:58 → 07:00] D, okay. [07:00 → 07:03] And any recreational drugs like marijuana? [07:03 → 07:05] P, um. [07:05 → 07:09] No marijuana, but I have used crystal meth in the past. [07:09 → 07:11] D, okay. [07:11 → 07:14] And when was the last time that you used crystal meth? [07:14 → 07:16] P, um. [07:16 → 07:18] Six days ago. [07:18 → 07:20] D, six days ago. [07:20 → 07:21] Okay. [07:21 → 07:23] And how often do you use crystal meth? [07:23 → 07:25] P, um. [07:25 → 07:27] I would say a couple of times a month. [07:27 → 07:30] D, a couple of times a month. [07:30 → 07:31] Okay. [07:31 → 07:32] All right. [07:32 → 07:35] And for how long have you been using crystal meth? [07:35 → 07:38] P, up for the last seven years. [07:38 → 07:40] D, seven years. [07:40 → 07:42] Okay.
Clinical Notes
Subjective
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Patient: The patient reports sudden onset chest pain on the left side that started 30 minutes ago.
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Pain Description: Describes the pain as dull with pressure on the chest, rated it as 7/10.
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Past Episodes: Denies any similar episodes of chest pain in the past.
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Symptoms: Reports shortness of breath since the pain started, worsens when moving around.
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Activity: Plays rugby and was tackled the day before the pain started.
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Medical History:
- High cholesterol and high blood pressure diagnosed.
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Takes medications for blood pressure (lisinopril), cholesterol (rosuvastatin), and a multivitamin.
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Social History:
- Smokes half a pack to a pack of cigarettes daily for the last 20 years.
- Used crystal meth a couple of times a month for the last seven years, last use was six days ago.
Objective
- No objective findings provided.
Assessment
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Acute Chest Pain: Sudden onset chest pain on the left side, described as dull with pressure, rated 7/10.
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Cardiovascular Risk Factors:
- History of high cholesterol and high blood pressure.
- Smoking history of 20 years.
- Crystal methamphetamine use.
Plan
- Immediate Referral:
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Immediate evaluation for acute chest pain to rule out cardiac causes.
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Cardiovascular Evaluation:
- ECG to assess for any acute cardiac abnormalities.
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Cardiac enzymes to rule out myocardial infarction.
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Substance Use Counseling:
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Referral to a substance abuse counselor for crystal methamphetamine use.
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Smoking Cessation:
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Provide resources and support for smoking cessation.
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Follow-Up:
- Schedule a follow-up appointment to review test results and adjust management accordingly.