🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-26 13:44:15

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: Sharp pain on the left side after intense cardio lasting 5-10 minutes, relieved by rest.

  • Associated Symptoms:

    • Sometimes feels a little out of breath during episodes.

Objective

  • No relevant data.

Assessment

  1. Chest Discomfort:
    • Differential diagnosis includes musculoskeletal or cardiac etiology.
    • Symptoms triggered by intense cardio, lasting 5-10 minutes, with associated shortness of breath.

Plan

  1. Diagnostics:

    • Order an ECG and a treadmill stress test to rule out cardiac issues.

  2. Activity Modification:

    • Advise the patient to avoid high-intensity intervals until test results are available.

  3. Follow-Up:

    • Schedule a follow-up appointment after the tests to discuss further management based on results.
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