🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-30 12:00:49

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><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></div></td></tr><tr><td id="fragmentid_2"><div><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></div></td></tr><tr><td id="fragmentid_3"><div><p><strong>Doctor</strong>: Any shortness of breath, nausea, or palpitations?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>Patient</strong>: Sometimes I feel a little out of breath, but I thought it was normal.</p></div></td></tr><tr><td id="fragmentid_5"><div><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></div></td></tr><tr><td id="fragmentid_6"><div><p><strong>Patient</strong>: Okay, I'll scale back a bit.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong>Doctor</strong>: Good. We'll follow up after the test. It's always better to be safe, especially with chest symptoms.</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong>Patient</strong>: Thank you, Dr.. I appreciate it.</p></div></td></tr></tbody>

Clinical Notes

SOAP Note

Subjective:

The patient, Omit, presents with chest discomfort experienced after intense cardio workouts. He describes the pain as sharp on the left side, lasting 5 to 10 minutes, and resolving with rest. He reports occasional feelings of being out of breath but previously considered it normal.

Objective:

No specific objective findings provided in the transcription.

Assessment:

Possible musculoskeletal chest pain exacerbated by intense cardio workouts. Differential diagnosis includes cardiac issues. Plan for further evaluation to rule out cardiac involvement: 1. Order an ECG and a treadmill stress test. 2. Advise the patient to avoid high-intensity intervals until test results are available.

Plan:

  1. Instruct the patient to scale back on the intensity of workouts.
  2. Schedule a follow-up appointment after the tests to review the results and determine the next steps.
  3. Emphasize the importance of caution with chest symptoms and the need for further evaluation for accurate diagnosis and management.
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