🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2025-07-30 09:24:42
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 class="SPEAKER-01">SPEAKER-01:</strong> and a stress test. These will give us insights into your</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Patient, is it serious? Dr., it could be. But the good news is, early diagnosis</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> outcomes. Depending on the results, we might need medication or lifestyle</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Patient, what kind of lifestyle changes? Dr., a heart -healthy diet,</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> stress management, and medication compliance. Also, no smoking if applicable.</p></div></td></tr></tbody>
Clinical Notes
SOAP Note
Subjective:
The 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 due to stress or fatigue, the discomfort has been increasing in frequency. The tightness is mainly centralized in the chest and typically subsides with rest. Additionally, the patient experiences quick shortness of breath and occasional lightheadedness.
Objective:
- Medical history includes high blood pressure, and a family history of heart disease (father had a heart attack in his early 50s).
- No specific physical examination findings provided in the transcription.
Assessment:
Possible angina due to reduced blood flow to the heart, considering the symptoms of chest tightness, shortness of breath, and lightheadedness. Increased risk due to a history of high blood pressure and family history of heart disease. Further diagnostic evaluation is necessary to confirm the diagnosis.
Plan:
- Order an ECG, echocardiogram, and a stress test to assess the heart's performance and confirm the presence of angina.
- Depending on the test results, consider medication and lifestyle modifications.
- Lifestyle changes may include adopting a heart-healthy diet, stress management techniques, ensuring medication compliance, and cessation of smoking if applicable.
- Emphasize the importance of early diagnosis for better outcomes and encourage the patient to follow up for further management based on the test results.