🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-08-01 10:21:53
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>: Okay, and where is the pain exactly?</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong>Patient</strong>: It's just right over on the left side.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong>Doctor</strong>: Okay, and when did this pain start?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>Patient</strong>: It started just 30 minutes ago.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong>Doctor</strong>: Okay, and did it just come on randomly or were you doing something strenuous?</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong>Patient</strong>: I was just juggling the driveway and it came on.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong>Doctor</strong>: Okay, and has that pain been getting worse at all over the last half an hour?</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong>Patient</strong>: No, it just came on suddenly and it's a, uh, I'm sorry. Yeah, the pain has been there this whole time and it's gotten worse ever since it started.</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong>Doctor</strong>: Okay, and how would you describe the pain? Is it kind of like an aching pain or is it a sharp or tight tightness kind of pain? How would you describe it?</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong>Patient</strong>: It feels dull. I feel like there's a lot of pressure on my chest.</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong>Doctor</strong>: And how do you rate the pain right now on a scale of 0 to 10, 0 being the least amount of pain you felt in your life, 10 being the worst.</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong>Patient</strong>: Uh, 7.</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong>Doctor</strong>: 7, okay. Have you had New York similar episodes before?</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong>Patient</strong>: No, I've never had any chest pain before.</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong>Doctor</strong>: Okay, and is the pain just staying in the region of the left chest area that you mentioned or is it traveling to any other part of your body?</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong>Patient</strong>: No, I'm kind of just feeling it right here. On the left side.</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong>Doctor</strong>: Okay, uh, is there anything that you do that makes the pain either get worse or go away or like get better?</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong>Patient</strong>: Uh, I think it's a bit bit worse if I'm moving around or when I was walking in here. I think it made it a bit worse, but nothing has seemed to make it any better since it's starting.</p></div></td></tr><tr><td id="fragmentid_19"><div><p><strong>Doctor</strong>: Okay, and does it change at all from you changing positions like if you're standing up versus sitting down or laying down?</p></div></td></tr><tr><td id="fragmentid_20"><div><p><strong>Patient</strong>: I think it's a little bit worse when I'm laying down.</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong>Doctor</strong>: Okay, and other than the pain that you've been having, have you been having any other symptoms like a cough or difficulty breathing or any pain when you're breathing in or out?</p></div></td></tr><tr><td id="fragmentid_22"><div><p><strong>Patient</strong>: Uh, I felt a little bit assured of breath or having difficulty breathing since yesterday when the sorry since the pain started, but adjust the difficulty breathing.</p></div></td></tr><tr><td id="fragmentid_23"><div><p><strong>Doctor</strong>: Okay, and have you recently injured your chest or surrounding area at all? Like from a fall or anything like that?</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong>Patient</strong>: I do I play rugby and was tackled by another player yesterday. But but my chest felt fine after that.</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong>Doctor</strong>: Okay so but the pain just started half an hour ago.</p></div></td></tr><tr><td id="fragmentid_26"><div><p><strong>Patient</strong>: Yeah.</p></div></td></tr><tr><td id="fragmentid_27"><div><p><strong>Doctor</strong>: Okay, have you been traveling at all recently?</p></div></td></tr><tr><td id="fragmentid_28"><div><p><strong>Patient</strong>: No, been at home.</p></div></td></tr><tr><td id="fragmentid_29"><div><p><strong>Doctor</strong>: Okay, has anyone around you been sick at all?</p></div></td></tr><tr><td id="fragmentid_30"><div><p><strong>Patient</strong>: No.</p></div></td></tr><tr><td id="fragmentid_31"><div><p><strong>Doctor</strong>: Okay, have you been having any symptoms like nausea or vomiting or any fevers or chills?</p></div></td></tr><tr><td id="fragmentid_32"><div><p><strong>Patient</strong>: No nausea or vomiting, but I do feel a little bit hot today.</p></div></td></tr><tr><td id="fragmentid_33"><div><p><strong>Doctor</strong>: Okay, but have you measured your temperature at all?</p></div></td></tr><tr><td id="fragmentid_34"><div><p><strong>Patient</strong>: But I did and it was 38 degrees.</p></div></td></tr><tr><td id="fragmentid_35"><div><p><strong>Doctor</strong>: Okay, and have you been having any kind of swelling in your legs or feet?</p></div></td></tr><tr><td id="fragmentid_36"><div><p><strong>Patient</strong>: No swelling in my legs.</p></div></td></tr><tr><td id="fragmentid_37"><div><p><strong>Doctor</strong>: Okay, have you been feeling tired at all, like increasingly fatigued?</p></div></td></tr><tr><td id="fragmentid_38"><div><p><strong>Patient</strong>: No, my energy has been good.</p></div></td></tr><tr><td id="fragmentid_39"><div><p><strong>Doctor</strong>: Have you been having any kind of thumping or palpitations or feel like your heart has been racing at all?</p></div></td></tr><tr><td id="fragmentid_40"><div><p><strong>Patient</strong>: It all hit does feel like it's beating faster right now. It usually only feels like this when I'm playing sports.</p></div></td></tr><tr><td id="fragmentid_41"><div><p><strong>Doctor</strong>: Okay, and have you noticed any changes in your skin at all? Any rashes?</p></div></td></tr><tr><td id="fragmentid_42"><div><p><strong>Patient</strong>: No rashes.</p></div></td></tr><tr><td id="fragmentid_43"><div><p><strong>Doctor</strong>: Okay, have you had any cough or runny nose or sore throat? Any kind of those symptoms and in the past month?</p></div></td></tr><tr><td id="fragmentid_44"><div><p><strong>Patient</strong>: A few weeks ago I was a little runny, but that went away on its own. I haven't had any cough.</p></div></td></tr><tr><td id="fragmentid_45"><div><p><strong>Doctor</strong>: Okay, and have you been feeling dizzy at all or have you fainted?</p></div></td></tr><tr><td id="fragmentid_46"><div><p><strong>Patient</strong>: No dizziness and unknown I haven't fainted at all.</p></div></td></tr><tr><td id="fragmentid_47"><div><p><strong>Doctor</strong>: Okay, just a few more questions. Have you had any diagnosis made by any physician or anything like diabetes or high blood pressure?</p></div></td></tr><tr><td id="fragmentid_48"><div><p><strong>Patient</strong>: Yeah, I've been told I have high cholesterol and high blood pressure.</p></div></td></tr><tr><td id="fragmentid_49"><div><p><strong>Doctor</strong>: Okay, and do you take any medications for these things?</p></div></td></tr><tr><td id="fragmentid_50"><div><p><strong>Patient</strong>: Um, I do take medications for both blood pressure and cholesterol, rosyavastatin, and umlisynapril and I take a multivitamin.</p></div></td></tr><tr><td id="fragmentid_51"><div><p><strong>Doctor</strong>: Okay, and do you have any allergies to any medications at all?</p></div></td></tr><tr><td id="fragmentid_52"><div><p><strong>Patient</strong>: No allergies.</p></div></td></tr><tr><td id="fragmentid_53"><div><p><strong>Doctor</strong>: Okay, have you had all in the past been hospitalized for any reason?</p></div></td></tr><tr><td id="fragmentid_54"><div><p><strong>Patient</strong>: No hospitalizations.</p></div></td></tr><tr><td id="fragmentid_55"><div><p><strong>Doctor</strong>: Any previous surgeries?</p></div></td></tr><tr><td id="fragmentid_56"><div><p><strong>Patient</strong>: No.</p></div></td></tr><tr><td id="fragmentid_57"><div><p><strong>Doctor</strong>: Okay, and within your family has anyone passed away from a heart attack or any cancers that run in the family?</p></div></td></tr><tr><td id="fragmentid_58"><div><p><strong>Patient</strong>: No.</p></div></td></tr><tr><td id="fragmentid_59"><div><p><strong>Doctor</strong>: Okay, and currently right now, do you live alone? Do you live with someone? And where do you live, like an apartment or house?</p></div></td></tr><tr><td id="fragmentid_60"><div><p><strong>Patient</strong>: I live in a house with um, my parents.</p></div></td></tr><tr><td id="fragmentid_61"><div><p><strong>Doctor</strong>: Okay, and do you currently work?</p></div></td></tr><tr><td id="fragmentid_62"><div><p><strong>Patient</strong>: Yeah, I drive a bus for the city.</p></div></td></tr><tr><td id="fragmentid_63"><div><p><strong>Doctor</strong>: Okay, and in your daily routine, would you say you get enough exercise throughout the week?</p></div></td></tr><tr><td id="fragmentid_64"><div><p><strong>Patient</strong>: Yeah, usually on Sundays I'll go for a run.</p></div></td></tr><tr><td id="fragmentid_65"><div><p><strong>Doctor</strong>: Okay, and how about your diet? Well, how's your diet like, just regularly?</p></div></td></tr><tr><td id="fragmentid_66"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Have you had any diagnosis made by any physician or anything like diabetes or high blood</p></div></td></tr><tr><td id="fragmentid_67"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, yeah, I've been told I have high cholesterol and high</p></div></td></tr><tr><td id="fragmentid_68"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> okay, and do you take any medications</p></div></td></tr><tr><td id="fragmentid_69"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, um, I do take medications for both blood</p></div></td></tr><tr><td id="fragmentid_70"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> rosyavastatin, and umlisynapril and I take a</p></div></td></tr><tr><td id="fragmentid_71"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and do you have any allergies to any</p></div></td></tr><tr><td id="fragmentid_72"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no allergies.</div></td></tr><tr><td id="fragmentid_73"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, have you had all in the past been hospitalized</p></div></td></tr><tr><td id="fragmentid_74"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no hospitalizations.</div></td></tr><tr><td id="fragmentid_75"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: D, any previous surgeries?</div></td></tr><tr><td id="fragmentid_76"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no.</div></td></tr><tr><td id="fragmentid_77"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and within your family has anyone passed away from a heart attack or any</p></div></td></tr><tr><td id="fragmentid_78"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no.</div></td></tr><tr><td id="fragmentid_79"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and currently right now,</p></div></td></tr><tr><td id="fragmentid_80"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Do you live with someone?</div></td></tr><tr><td id="fragmentid_81"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> And where do you live, like an</p></div></td></tr></tbody>
Clinical Notes
SOAP Note
Subjective
The patient reports experiencing pain on the left side of the chest that started suddenly 30 minutes ago while juggling. The pain is described as dull with pressure on the chest, rated 7/10 in intensity. The patient denies any similar episodes in the past, and the pain has been worsening since onset. Additionally, the patient mentions feeling short of breath since the pain started.
Objective
- No visible signs of distress.
- Patient reports pain localized to the left chest area, with no radiation to other parts of the body.
- Pain worsens with movement and lying down.
- Patient mentions feeling hot with a temperature of 38 degrees.
- Denies swelling in legs, fatigue, palpitations, or skin changes.
- No recent travel history or sick contacts mentioned.
Assessment
- Acute chest pain on the left side, possibly musculoskeletal in nature.
- Shortness of breath associated with chest pain.
- Elevated temperature of 38 degrees.
Plan
- Further evaluation to rule out cardiac issues with an ECG.
- Consider chest X-ray to assess for any underlying lung pathology.
- Monitor vital signs and oxygen saturation.
- Provide pain relief as needed.
- Advise the patient to follow up if symptoms persist or worsen.