🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-29 07:23:33

Transcript

Patient: 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.<br><br>Doctor: 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?<br><br>Patient: For about three weeks now. At first, I thought it was stress or fatigue, but it's happening more often now.<br><br>Doctor: Is the tightness located in the center of your chest or on one side?<br><br>Patient: Mostly in the center. It usually goes away after a few minutes of rest.<br><br>Doctor: That could be angina, which is due to reduced blood flow to the heart. Any shortness of breath, nausea, or dizziness?<br><br>Patient: Yes, I do get winded quickly and sometimes feel light-headed.<br><br>Doctor: Do you have any medical history, like high blood pressure, diabetes, or a family history of heart disease?<br><br>Patient: I have high blood pressure and my father had a heart attack in his early 50s.<br><br>Doctor: 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.<br><br>Patient: Is it serious?<br><br>Doctor: 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.<br><br>Patient: What kind of lifestyle changes?<br><br>Doctor: A heart-healthy diet, regular light exercise, stress management, and medication compliance. Also, no smoking if applicable.<br><br>Patient: I don't smoke. But I do need to improve my diet and activity levels.<br><br>Doctor: That's a good start. We'll schedule the tests and review everything together. In the meantime, avoid heavy exertion.<br><br>Patient: Thank you, Dr.. I appreciate the care.<br><br>Doctor: You're welcome. We'll take good care of you.<br><br>

Clinical Notes

Patient Information

  • Patient Name: Not provided
  • Age / DOB: Not provided
  • Gender: Not provided
  • Contact Number: Not provided
  • Date of Visit: Not provided

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 frequency of occurrence has increased. The discomfort is mainly located in the center of the chest and subsides after resting. Additionally, the patient experiences quick shortness of breath and occasional lightheadedness.

Objective

No objective findings provided.

Assessment

The patient presents with symptoms suggestive of angina, possibly due to reduced blood flow to the heart. The presence of high blood pressure and a family history of heart disease, specifically a father who had a heart attack in his early 50s, increases the risk of cardiovascular issues.

Plan

  1. Perform investigations:
  2. ECG
  3. Echocardiogram

  4. Stress test

  5. Lifestyle modifications:

  6. Adopt a heart-healthy diet
  7. Engage in regular light exercise
  8. Implement stress management techniques
  9. Ensure medication compliance

  10. Stop smoking if applicable

  11. Follow-up:

  12. Schedule a follow-up to review test results and discuss further management.
  13. Advise the patient to avoid heavy exertion until further evaluation.

This structured clinical note is based on the provided transcription and follows the SOAP format for clear documentation.

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