🩺 Record Detail
Patient Info
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><div><b>Doctor</b>: 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.</div><br>
Clinical Notes
Patient Information - Patient Name: - Date of Birth: - Date of Visit: - Gender: - Patient ID:
Chief Complaint (CC): "Patient reports feeling a strange tightness in the chest, especially after physical activity, for the past three weeks."
History of Present Illness (HPI): - Onset: Three weeks ago - Duration: Persistent - Location: Center of the chest - Quality: Not sharp, uncomfortable - Associated Symptoms: Shortness of breath, light-headedness
Past Medical History (PMH): - Chronic Conditions: High blood pressure - Family History: Father had a heart attack in his early 50s
Physical Examination (PE): - General Appearance: Well-appearing - Cardiovascular: Chest tightness on exertion
Assessment: - Primary Diagnosis: Angina - Secondary Diagnosis: High blood pressure
Plan: - Investigations: ECG, echocardiogram, stress test - Lifestyle Changes: Depending on results - Medications: Depending on diagnosis - Follow-Up: Based on test results and diagnosis