🩺 Record Detail
Patient Info
Transcript
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<th><strong>Original Transcription</strong></th>
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<tbody><tr><td id="fragmentid_1"><div><p><strong class="Doctor">Doctor</strong>: OK, and where is the pain exactly?</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="Patient">Patient</strong>: It's just right over on the on the left side.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="Doctor">Doctor</strong>: OK, and when did this pain start?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="Patient">Patient</strong>: It started just 30 minutes ago.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="Doctor">Doctor</strong>: OK, and did it just come on randomly or were you doing something strenuous?</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="Patient">Patient</strong>: I was just juggling the driveway and it came on.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="Doctor">Doctor</strong>: OK, and has that pain been getting worse at all over the last half an hour?</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="Patient">Patient</strong>: No, it just came on suddenly and it's uh, uh, I'm sorry. Yeah the pain has been there this whole time and it's gotten worse ever since it started.</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="Doctor">Doctor</strong>: OK, and how would you describe the pain? Is it kind of like an aching pain or is it a sharp or tight tightness kind of pain? How would you describe it?</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="Patient">Patient</strong>: It feels dull. I feel like there's a lot of pressure on my chest.</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="Doctor">Doctor</strong>: And how do you rate the pain right now on a scale of 0 to 10, 0 being the least amount of pain you felt in your life, 10 being the worst?</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="Patient">Patient</strong>: Uh, 7.</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="Doctor">Doctor</strong>: 7, OK. Have you had New York similar episodes before?</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="Patient">Patient</strong>: No, I've never had any chest pain before.</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="Doctor">Doctor</strong>: OK, and is the pain just staying in the region of the left chest area that you mentioned or is it traveling to any other part of your body?</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="Patient">Patient</strong>: No, I'm kind of just feeling it right here. On the left side.</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="Doctor">Doctor</strong>: OK, uh, is there anything that you do that makes the pain either get worse or go away or like get better?</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="Patient">Patient</strong>: Uh, I think it's a bit bit worse if I'm moving around or when I was walking in here. I think it it made it a bit worse, but nothing has seemed to make it any better since it's starting.</p></div></td></tr><tr><td id="fragmentid_19"><div><p><strong class="Doctor">Doctor</strong>: OK, and does it change at all from you changing positions like if you're standing up versus sitting down or laying down?</p></div></td></tr><tr><td id="fragmentid_20"><div><p><strong class="Patient">Patient</strong>: I think it's a little bit worse when I when I'm laying down.</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="Doctor">Doctor</strong>: OK, and other than the pain that you've been having, have you been having any other symptoms like a cough or difficulty breathing or any pain when you're breathing in or out?</p></div></td></tr><tr><td id="fragmentid_22"><div><p><strong class="Patient">Patient</strong>: Uh, I felt a little bit uh short of breath or having difficulty breathing since yesterday when the sorry since the pain started, but uh just the difficulty breathing.</p></div></td></tr><tr><td id="fragmentid_23"><div><p><strong class="Doctor">Doctor</strong>: OK, and have you recently injured your chest or surrounding area at all? Like from a fall or anything like that?</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong class="Patient">Patient</strong>: I do I play rugby and was tackled by another player yesterday. But but my chest felt fine after that.</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong class="Doctor">Doctor</strong>: OK, so but the pain just started half an hour ago.</p></div></td></tr><tr><td id="fragmentid_26"><div><p><strong class="Patient">Patient</strong>: Yeah.</p></div></td></tr><tr><td id="fragmentid_27"><div><p><strong class="Doctor">Doctor</strong>: OK, have you have you been traveling at all recently?</p></div></td></tr><tr><td id="fragmentid_28"><div><p><strong class="Patient">Patient</strong>: No, been at home.</p></div></td></tr><tr><td id="fragmentid_29"><div><p><strong class="Doctor">Doctor</strong>: OK, has anyone around you been sick at all?</p></div></td></tr><tr><td id="fragmentid_30"><div><p><strong class="Patient">Patient</strong>: No.</p></div></td></tr><tr><td id="fragmentid_31"><div><p><strong class="Doctor">Doctor</strong>: OK, have you been having any symptoms like nausea or vomiting or any fevers or chills?</p></div></td></tr><tr><td id="fragmentid_32"><div><p><strong class="Patient">Patient</strong>: No nausea or vomiting, but I do feel a little bit hot today.</p></div></td></tr><tr><td id="fragmentid_33"><div><p><strong class="Doctor">Doctor</strong>: OK, but have you measured your temperature at all?</p></div></td></tr><tr><td id="fragmentid_34"><div><p><strong class="Patient">Patient</strong>: Uh, I did and it was 38 degrees.</p></div></td></tr><tr><td id="fragmentid_35"><div><p><strong class="Doctor">Doctor</strong>: OK, and have you been having any kind of swelling in your legs or feet?</p></div></td></tr><tr><td id="fragmentid_36"><div><p><strong class="Patient">Patient</strong>: Uh, no swelling in my legs.</p></div></td></tr><tr><td id="fragmentid_37"><div><p><strong class="Doctor">Doctor</strong>: OK, have you been feeling tired at all, like increasingly fatigued?</p></div></td></tr><tr><td id="fragmentid_38"><div><p><strong class="Patient">Patient</strong>: No, my energy has been good.</p></div></td></tr><tr><td id="fragmentid_39"><div><p><strong class="Doctor">Doctor</strong>: Have you been having any kind of thumping or palpitations or feel like your heart has been racing at all?</p></div></td></tr><tr><td id="fragmentid_40"><div><p><strong class="Patient">Patient</strong>: It does feel like it's beating faster right now. It usually only feels like this when I'm playing sports.</p></div></td></tr><tr><td id="fragmentid_41"><div><p><strong class="Doctor">Doctor</strong>: OK. And have you noticed any changes in your skin at all? Any rashes?</p></div></td></tr><tr><td id="fragmentid_42"><div><p><strong class="Patient">Patient</strong>: No rashes.</p></div></td></tr><tr><td id="fragmentid_43"><div><p><strong class="Doctor">Doctor</strong>: OK, have you had any cough or runny nose or sore throat? Any kind of those symptoms and in the past month?</p></div></td></tr><tr><td id="fragmentid_44"><div><p><strong class="Patient">Patient</strong>: A few weeks ago I was a little runny, but that went away on its own. I haven't had any cough.</p></div></td></tr><tr><td id="fragmentid_45"><div><p><strong class="Doctor">Doctor</strong>: OK, and have you been feeling dizzy at all or have you fainted?</p></div></td></tr><tr><td id="fragmentid_46"><div><p><strong class="Patient">Patient</strong>: No dizziness and uh no I haven't fainted at all.</p></div></td></tr><tr><td id="fragmentid_47"><div><p><strong class="Doctor">Doctor</strong>: OK. Just a few more questions. Have you had any diagnosis made by any physician or any anything like diabetes or high blood pressure?</p></div></td></tr><tr><td id="fragmentid_48"><div><p><strong class="Patient">Patient</strong>: Yeah, I've been told I have high cholesterol and high blood pressure.</p></div></td></tr><tr><td id="fragmentid_49"><div><p><strong class="Doctor">Doctor</strong>: OK, and do you take any medications for the these things?</p></div></td></tr><tr><td id="fragmentid_50"><div><p><strong class="Patient">Patient</strong>: Um, I do take medications for both blood pressure and cholesterol, rosuvastatin and umlicinopril and I take a multivitamin.</p></div></td></tr><tr><td id="fragmentid_51"><div><p><strong class="Doctor">Doctor</strong>: OK, and do you have any allergies to any medications at all?</p></div></td></tr><tr><td id="fragmentid_52"><div><p><strong class="Patient">Patient</strong>: No allergies.</p></div></td></tr><tr><td id="fragmentid_53"><div><p><strong class="Doctor">Doctor</strong>: OK, have you at all in the past been hospitalized for any reason?</p></div></td></tr><tr><td id="fragmentid_54"><div><p><strong class="Patient">Patient</strong>: No hospitalizations.</p></div></td></tr><tr><td id="fragmentid_55"><div><p><strong class="Doctor">Doctor</strong>: Any previous surgeries?</p></div></td></tr><tr><td id="fragmentid_56"><div><p><strong class="Patient">Patient</strong>: No.</p></div></td></tr><tr><td id="fragmentid_57"><div><p><strong class="Doctor">Doctor</strong>: OK, and within your family, has anyone passed away from a heart attack or any cancers that run in the family?</p></div></td></tr><tr><td id="fragmentid_58"><div><p><strong class="Patient">Patient</strong>: No.</p></div></td></tr><tr><td id="fragmentid_59"><div><p><strong class="Doctor">Doctor</strong>: OK, and currently right now, do you live alone? Do you live with someone? And where do you live, like an apartment or house?</p></div></td></tr><tr><td id="fragmentid_60"><div><p><strong class="Patient">Patient</strong>: I live in a house with um, my parents.</p></div></td></tr><tr><td id="fragmentid_61"><div><p><strong class="Doctor">Doctor</strong>: OK, and do you currently work?</p></div></td></tr><tr><td id="fragmentid_62"><div><p><strong class="Patient">Patient</strong>: Yeah, I drive a bus for the city.</p></div></td></tr><tr><td id="fragmentid_63"><div><p><strong class="Doctor">Doctor</strong>: OK, and in your daily routine, would you say you get enough exercise throughout the week?</p></div></td></tr><tr><td id="fragmentid_64"><div><p><strong class="Patient">Patient</strong>: Uh yeah, usually on Sundays I'll go for a run.</p></div></td></tr><tr><td id="fragmentid_65"><div><p><strong class="Doctor">Doctor</strong>: OK, and how about your diet? Well, how's your diet like, just regularly?</p></div></td></tr><tr><td id="fragmentid_66"><div><p><strong class="Patient">Patient</strong>: Uh, usually I feel like it's fairly balanced overall, I might I eat out a little bit too often, but try to eat as many vegetables as I can.</p></div></td></tr><tr><td id="fragmentid_67"><div><p><strong class="Doctor">Doctor</strong>: OK, and do you smoke cigarettes at all?</p></div></td></tr><tr><td id="fragmentid_68"><div><p><strong class="Patient">Patient</strong>: I do yes. Been smoking for the last 20 years roughly.</p></div></td></tr><tr><td id="fragmentid_69"><div><p><strong class="Doctor">Doctor</strong>: OK, how much do you smoke on an average day?</p></div></td></tr><tr><td id="fragmentid_70"><div><p><strong class="Patient">Patient</strong>: About a half a pack to a pack a day.</p></div></td></tr><tr><td id="fragmentid_71"><div><p><strong class="Doctor">Doctor</strong>: OK, and do you drink?</p></div></td></tr><tr><td id="fragmentid_72"><div><p><strong class="Patient">Patient</strong>: No alcohol.</p></div></td></tr><tr><td id="fragmentid_73"><div><p><strong class="Doctor">Doctor</strong>: OK, and any recreational drugs like marijuana?</p></div></td></tr><tr><td id="fragmentid_74"><div><p><strong class="Patient">Patient</strong>: Um, no marijuana, but I have used crystal meth in the past.</p></div></td></tr><tr><td id="fragmentid_75"><div><p><strong class="Doctor">Doctor</strong>: OK, and when was the last time that you used crystal meth?</p></div></td></tr><tr><td id="fragmentid_76"><div><p><strong class="Patient">Patient</strong>: Um, six days ago.</p></div></td></tr><tr><td id="fragmentid_77"><div><p><strong class="Doctor">Doctor</strong>: Six days ago, OK, and how often do you use crystal meth?</p></div></td></tr><tr><td id="fragmentid_78"><div><p><strong class="Patient">Patient</strong>: Um, I would say a couple of times a month.</p></div></td></tr><tr><td id="fragmentid_79"><div><p><strong class="Doctor">Doctor</strong>: A couple of times a month, OK. Alright, and for how long have you been using crystal meth?</p></div></td></tr><tr><td id="fragmentid_80"><div><p><strong class="Patient">Patient</strong>: Uh for the last seven years.</p></div></td></tr><tr><td id="fragmentid_81"><div><p><strong class="Doctor">Doctor</strong>: Seven years, OK.</p></div></td></tr></tbody>
Clinical Notes
Subjective
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Patient: PATIENT_NAME, age not specified.
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Primary Concern: Sudden onset of chest pain.
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Pain located on the left side of the chest, described as dull with pressure sensation.
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Pain started 30 minutes prior to consultation and has worsened since onset.
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Associated with shortness of breath and a fever of 38 degrees Celsius.
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Family History:
- No family history of heart attacks or cancers.
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Lifestyle Factors:
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Smokes about half a pack to a pack of cigarettes per day for the last 20 years.
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No alcohol consumption.
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Occasional use of crystal meth, last used six days ago, with a history of use for seven years.
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Psychosocial Stressors:
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Lives with parents in a house.
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Works as a city bus driver.
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Objective
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Medical History:
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Diagnosed with high cholesterol and high blood pressure.
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Current medications include rosuvastatin, lisinopril, and a multivitamin.
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No allergies to medications.
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Behavioral Observations:
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Patient reports no recent hospitalizations or surgeries.
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No recent travel or exposure to sick individuals.
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Assessment
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Chest Pain: Likely non-cardiac in origin, given the sudden onset and association with recent physical activity and substance use.
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Hypertension and Hyperlipidemia: Managed with current medications.
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Substance Use: Crystal meth use may contribute to cardiovascular symptoms.
Plan
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Diagnostics:
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Consider ECG and chest X-ray to rule out cardiac causes of chest pain.
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Monitor vital signs and oxygen saturation.
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Lifestyle Modifications:
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Strongly advise smoking cessation.
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Encourage reduction or cessation of crystal meth use.
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Medical Management:
- Continue current medications for hypertension and hyperlipidemia.
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Follow-Up:
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Schedule follow-up appointment to reassess symptoms and discuss lifestyle changes.
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Consider referral to a substance abuse counselor for support in reducing crystal meth use.
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Medications | Name | Brand | Dosage | Frequency | Duration (Days) | |---------------|-------|----------|-----------------------------------------|-----------------| | Rosuvastatin | – | unspecified | unspecified | unspecified | | Lisinopril | – | unspecified | unspecified | unspecified | | Multivitamin | – | unspecified | unspecified | unspecified |