🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-29 13:05:56

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><div><b>Patient</b>: Is it serious?</div><br>

Clinical Notes

Patient:

  • Chief Complaint (CC): Patient reports feeling a strange tightness in the chest, especially after physical activity like climbing stairs or walking briskly. Describes it as uncomfortable, not sharp pain.

Subjective:

Patient has been experiencing chest tightness for about three weeks, initially attributing it to stress or fatigue. The symptom has been increasing in frequency.

Objective:

  • No objective findings mentioned.

Assessment:

Possible angina due to reduced blood flow to the heart, considering the location of the tightness in the center of the chest and associated symptoms of shortness of breath and lightheadedness. Increased risk due to a history of high blood pressure and family history of heart disease.

Plan:

  1. Perform an Electrocardiogram (ECG), echocardiogram, and stress test to assess heart function and blood flow.
  2. Further evaluation based on test results to determine the underlying cause and severity of the symptoms.
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