🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-05-09 12:10:46

Transcript

[00:00 → 00:05] Stethoscope emoji, Dr. Patient Conversation, Cardiovascular Concern
[00:05 → 00:13] Patient, Good Morning, Dr. I've been feeling a strange tightness in my chest lately, especially
[00:13 → 00:19] after climbing stairs or walking briskly. It's not sharp pain, but it's uncomfortable.
[00:19 → 00:26] Dr. Good Morning. I'm glad you came in. Chest tightness can be an early sign of several
[00:26 → 00:32] conditions, including cardiovascular issues. How long has this been happening?
[00:32 → 00:37] Patient, for about three weeks now. At first, I thought it was stress or fatigue, but
[00:37 → 00:43] it's happening more often now. Dr., is the tightness located in the center
[00:43 → 00:49] of your chest or on one side? Patient, mostly in the center. It usually goes away
[00:49 → 00:54] after a few minutes of rest. Dr., that could be angina, which is due
[00:54 → 01:00] to reduced blood flow to the heart. Any shortness of breath, nausea, or dizziness?
[01:00 → 01:06] Patient, yes, I do get winded quickly and sometimes feel light-headed.
[01:06 → 01:12] Dr., do you have any medical history, like high blood pressure, diabetes, or a family
[01:12 → 01:17] history of heart disease? Patient, I have high blood pressure and my
[01:17 → 01:24] father had a heart attack in his early fifties. Dr., that increases your risk. We'll need
[01:24 → 01:31] to perform an ECG, echocardiogram, and a stress test. These will give us insights into your
[01:31 → 01:39] heart's performance. Patient, is it serious? Dr, it could be. But the good news is, early
[01:39 → 01:44] diagnosis leads to better outcomes. Depending on the results, we might need medication
[01:44 → 01:50] or lifestyle changes. Patient, what kind of lifestyle changes?
[01:50 → 01:58] Dr, a heart-healthy diet, regular light exercise, stress management, and medication compliance.
[01:58 → 02:04] Also, no smoking if applicable. Patient, I don't smoke. But I do need to improve
[02:04 → 02:11] my diet and activity levels. Dr, that's a good start. We'll schedule the tests and review
[02:11 → 02:16] everything together. In the meantime, avoid heavy exertion.
[02:16 → 02:23] Patient, thank you, doctor. I appreciate the care. Doctor, you're welcome. We'll take
[02:23 → 02:24] good care of you.

Clinical Notes

Subjective

  • Patient: Reports feeling a strange tightness in the chest, especially after physical activities like climbing stairs or walking briskly. Describes the sensation as uncomfortable but not sharp pain, occurring for about three weeks and increasing in frequency.

  • Location of Tightness: Mostly in the center of the chest, alleviated after resting for a few minutes.

  • Associated Symptoms: Experiences quick shortness of breath and occasional lightheadedness.

  • Medical History:

  • High blood pressure.
  • Family history of heart disease (father had a heart attack in his early fifties).

Objective

  • No specific objective data provided.

Assessment

  1. Angina: Suspected due to the presentation of chest tightness, especially with physical exertion, and associated symptoms like shortness of breath and lightheadedness.

  2. Cardiovascular Risk:

  3. Increased due to the patient's medical history of high blood pressure and family history of heart disease.

Plan

  1. Diagnostics:

  2. Order an ECG, echocardiogram, and stress test to evaluate heart function and assess for any cardiovascular issues.

  3. Lifestyle Modifications:

  4. Recommend a heart-healthy diet.
  5. Encourage regular light exercise.
  6. Stress management techniques.
  7. Emphasize medication compliance.

  8. Advise against smoking.

  9. Follow-Up:

  10. Schedule a follow-up to review test results and discuss further management options.
  11. Instruct the patient to avoid heavy exertion until further evaluation is completed.
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