🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-07-30 09:33:11
Transcript
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<tbody><tr><td id="fragmentid_1"><div><p><strong>Patient</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong>Doctor</strong>: 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?</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong>Patient</strong>: For about three weeks now. At first, I thought it was stress or fatigue, but it's happening more often now.</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>Doctor</strong>: Is the tightness located in the center of your chest or on one side?</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong>Patient</strong>: Mostly in the center. It usually goes away after a few minutes of rest.</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong>Doctor</strong>: That could be angina, which is due to reduced blood flow to the heart. Any shortness of breath, nausea, or dizziness?</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong>Patient</strong>: Yes, I do get winded quickly and sometimes feel light-headed.</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong>Doctor</strong>: Do you have any medical history, like high blood pressure, diabetes, or a family history of heart disease?</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong>Patient</strong>: I have high blood pressure and my father had a heart attack in his early 50s.</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong>Doctor</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong>Patient</strong>: Is it serious?</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong>Doctor</strong>: It could be. But the good news is, early diagnosis leads to better outcomes. Depending on the results, we might need medication or lifestyle changes.</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong>Patient</strong>: What kind of lifestyle changes?</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong>Doctor</strong>: A heart-healthy diet, regular light exercise, stress management, and medication compliance. Also, no smoking if applicable.</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong>Patient</strong>: I don't smoke. But I do need to improve my diet and activity levels.</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong>Doctor</strong>: That's a good start. We'll schedule the tests and review everything together. In the meantime, avoid heavy exertion.</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong>Patient</strong>: Thank you, Dr.. I appreciate the care.</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong>Doctor</strong>: You're welcome. We'll take good care of you.</p></div></td></tr></tbody>
Clinical Notes
SOAP Note
- Subjective:
- Patient reports feeling a strange tightness in the chest for about three weeks, especially after physical activities like climbing stairs or walking briskly. Initially thought to be related to stress or fatigue but now occurring more frequently. Describes the tightness as mostly in the center of the chest, which usually resolves after resting. Reports experiencing shortness of breath, getting winded quickly, and feeling light-headed.
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Patient has a history of high blood pressure, and the father had a heart attack in his early 50s.
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Objective:
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No specific objective findings provided in the transcription.
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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.
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Plan to perform ECG, echocardiogram, and stress test to evaluate heart function and determine the appropriate management.
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Plan:
- Schedule ECG, echocardiogram, and stress test for further evaluation.
- Emphasize the importance of lifestyle modifications including a heart-healthy diet, regular light exercise, stress management, and medication adherence.
- Advise against heavy exertion until further evaluation is completed.