🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-24 07:33:08

Transcript

<p><strong>Doctor</strong>: Hi, Omit! I see you've come in with some chest discomfort after your gym workouts. Can you describe what you're feeling?</p><p><strong>Patient</strong>: Hi, Doctor! It's a sharp pain on the left side that comes after intense cardio. It lasts about 5 to 10 minutes and goes away if I rest.</p><p><strong>Doctor</strong>: Any shortness of breath, nausea, or palpitations?</p><p><strong>Patient</strong>: Sometimes I feel a little out of breath, but I thought it was normal.</p><p><strong>Doctor</strong>: It could be musculoskeletal, but I want to rule out anything cardiac. We'll start with an ECG and a treadmill stress test. Also, try avoiding high intensity intervals until we get the results.</p><p><strong>Patient</strong>: Okay, I'll scale back a bit.</p><p><strong>Doctor</strong>: Good. We'll follow up after the test. It's always better to be safe, especially with chest symptoms.</p><p><strong>Patient</strong>: Thank you, Dr.. I appreciate it.</p>

Clinical Notes

Subjective

  • Patient: Omit.

  • Primary Concern: Sharp pain on the left side after intense cardio lasting 5 to 10 minutes, relieved by rest.

  • Symptoms:

  • Reports feeling a little out of breath at times.

Objective

  • No relevant data.

Assessment

  1. Chest Discomfort:

  2. Differential diagnosis includes musculoskeletal or cardiac origin.

  3. Exercise-induced Symptoms:

  4. Symptoms triggered by intense cardio, possibly indicating cardiac involvement.

Plan

  1. Diagnostics:

  2. Order an ECG and a treadmill stress test to rule out cardiac issues.

  3. Activity Modification:

  4. Advise avoiding high-intensity intervals until test results are obtained.

  5. Follow-Up:

  6. Schedule a follow-up appointment after the tests to discuss further management.
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