🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-06-04 12:09:20

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

  • Patient: The patient reports sudden onset chest pain on the left side that started 30 minutes ago.

  • Pain Description: Describes the pain as dull with pressure on the chest, rated it as 7/10.

  • Past Episodes: Denies any similar episodes of chest pain in the past.

  • Symptoms: Reports shortness of breath since the pain started, worsens when moving around.

  • Activity: Plays rugby and was tackled the day before the pain started.

  • Medical History:

  • High cholesterol and high blood pressure diagnosed.
  • Takes medications for blood pressure (lisinopril), cholesterol (rosuvastatin), and a multivitamin.

  • 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

  1. Acute Chest Pain: Sudden onset chest pain on the left side, described as dull with pressure, rated 7/10.

  2. Cardiovascular Risk Factors:

  3. History of high cholesterol and high blood pressure.
  4. Smoking history of 20 years.
  5. Crystal methamphetamine use.

Plan

  1. Immediate Referral:
  2. Immediate evaluation for acute chest pain to rule out cardiac causes.

  3. Cardiovascular Evaluation:

  4. ECG to assess for any acute cardiac abnormalities.
  5. Cardiac enzymes to rule out myocardial infarction.

  6. Substance Use Counseling:

  7. Referral to a substance abuse counselor for crystal methamphetamine use.

  8. Smoking Cessation:

  9. Provide resources and support for smoking cessation.

  10. Follow-Up:

  11. Schedule a follow-up appointment to review test results and adjust management accordingly.
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