🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-01 12:44:29

Transcript

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                                                   <th><strong>Original Transcription</strong></th>
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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:

  • The patient presents with chest discomfort experienced after intense cardio workouts. Describes it as a sharp pain on the left side lasting 5 to 10 minutes, relieved by rest. Reports occasional feelings of being out of breath.

  • Objective:

  • No objective findings provided in the transcription.

  • Assessment:

  • Differential Diagnosis:

    • Musculoskeletal chest pain.
    • Cardiac origin chest pain.

  • Plan:

  • Diagnostic Tests:
    • ECG and treadmill stress test to rule out cardiac issues.
  • Lifestyle Modification:
    • Advised the patient to avoid high-intensity intervals until test results are obtained.
  • Follow-up:
    • Scheduled a follow-up appointment after the tests to review results and determine further management.
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