🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-29 13:08:51

Transcript

<div><b>Patient</b>: Good Morning, Dr. I've been feeling a strange tightness in my chest lately, especially after climbing stairs or walking briskly. It's not sharp pain, but it's uncomfortable.</div><br><div><b>Doctor</b>: Good Morning. I'm glad you came in. Chest tightness can be an early sign of several conditions, including cardiovascular issues. How long has this been happening?</div><br><div><b>Patient</b>: For about three weeks now. At first, I thought it was stress or fatigue, but it's happening more often now.</div><br><div><b>Doctor</b>: Is the tightness located in the center of your chest or on one side?</div><br><div><b>Patient</b>: Mostly in the center. It usually goes away after a few minutes of rest.</div><br><div><b>Doctor</b>: That could be angina, which is due to reduced blood flow to the heart. Any shortness of breath, nausea, or dizziness?</div><br><div><b>Patient</b>: Yes, I do get winded quickly and sometimes feel light-headed.</div><br><div><b>Doctor</b>: Do you have any medical history, like high blood pressure, diabetes, or a family history of heart disease?</div><br><div><b>Patient</b>: I have high blood pressure and my father had a heart attack in his early 50s.</div><br><div><b>Doctor</b>: That increases your risk. We'll need to perform an ECG, echocardiogram, and a stress test. These will give us insights into your heart's performance.</div><br>

Clinical Notes

Patient Information

  • Patient Name: Not provided
  • Age / DOB: Not provided
  • Gender: Not provided
  • Contact Number: Not provided
  • Date of Visit: Not provided

Chief Complaint / Reason for Visit

The patient reports feeling a strange tightness in the chest, especially after physical activities like climbing stairs or walking briskly. The discomfort is not sharp but persistent for about three weeks.

Medical History

  • Chronic Illnesses:
  • High blood pressure
  • Family History:
  • Father had a heart attack in his early 50s

Vital Signs

  • Blood Pressure: Not documented
  • Pulse Rate: Not documented
  • Temperature: Not documented
  • Respiratory Rate: Not documented
  • Oxygen Saturation: Not documented
  • Weight: Not documented
  • Height: Not documented
  • BMI: Not documented

General Physical Examination

  • Cardiovascular:
  • Reports chest tightness
  • Respiratory:
  • Shortness of breath on exertion
  • Neurological:
  • Reports feeling light-headed

Assessment

Suspected angina due to chest tightness, possibly related to reduced blood flow to the heart. Increased risk due to a history of high blood pressure and family history of heart disease.

Plan

  1. Perform investigations:
  2. ECG
  3. Echocardiogram
  4. Stress test
  5. Evaluate heart's performance based on test results.
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