🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-01 12:33:46

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 presents with chest discomfort occurring after intense cardio workouts. The pain is described as sharp and located on the left side, lasting for about 5 to 10 minutes and subsiding with rest. The patient also reports feeling slightly out of breath at times.

Objective:

No specific objective findings provided in the transcription.

Assessment:

Possible musculoskeletal chest pain following intense exercise. Differential includes cardiac etiology due to the nature of the symptoms.

Plan:

  1. Perform an ECG and a treadmill stress test to rule out any cardiac issues.
  2. Advise the patient to avoid high-intensity intervals until test results are obtained.
  3. Follow up with the patient after the tests to review the findings.
  4. Emphasize the importance of caution with chest symptoms and the need for further evaluation.
  5. Patient to scale back on exercise intensity as discussed.

Follow-up: Schedule a follow-up appointment post-test results.

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