🩺 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
- Perform investigations:
- ECG
- Echocardiogram
- Stress test
- Evaluate heart's performance based on test results.