🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-07-30 10:47:08

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong>Patient</strong>: 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.</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong>Doctor</strong>: 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?</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong>Patient</strong>: For about three weeks now. At first, I thought it was stress or fatigue, but it's happening more often now.</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>Doctor</strong>: Is the tightness located in the center of your chest or on one side?</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong>Patient</strong>: Mostly in the center. It usually goes away after a few minutes of rest.</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong>Doctor</strong>: That could be angina, which is due to reduced blood flow to the heart. Any shortness of breath, nausea, or dizziness?</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong>Patient</strong>: Yes, I do get winded quickly and sometimes feel light-headed.</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong>Doctor</strong>: Do you have any medical history, like high blood pressure, diabetes, or a family history of heart disease?</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong>Patient</strong>: I have high blood pressure and my father had a heart attack in his early 50s.</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> breath, nausea, or dizziness? Patient, yes, I do get winded quickly and sometimes</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Dr., do you have any medical history, like high blood pressure, diabetes, or a</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> history of heart disease? Patient, I have high blood pressure and my father</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> in his early 50s. Dr., that increases your risk. We'll need to perform an ECG,</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> and a stress test. These will give us insights into your</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Patient, is it serious? Dr., it could be. But the good news is, early diagnosis</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> outcomes. Depending on the results, we might need medication or lifestyle</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Patient, what kind of lifestyle changes? Dr., a heart -healthy diet,</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> stress management, and medication compliance. Also, no smoking if applicable.</p></div></td></tr></tbody>

Clinical Notes

SOAP Note

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 discomfort has been increasing in frequency. The tightness is mainly located in the center of the chest and typically subsides after a few minutes of rest. The patient also experiences shortness of breath, quick onset of fatigue, and occasional lightheadedness.

Objective:

No specific objective findings provided in the transcription.

Assessment:

Based on the patient's symptoms of chest tightness, shortness of breath, and family history of heart disease (father had a heart attack in his early 50s), there is a concern for cardiovascular issues such as angina. The patient's history of high blood pressure further raises the suspicion. Further diagnostic evaluation is warranted.

Plan:

  1. Perform an electrocardiogram (ECG) and a stress test to assess cardiovascular function and detect any abnormalities.
  2. Depending on the test results, consider initiating medication or recommending lifestyle modifications.
  3. Discuss the importance of heart-healthy diet, stress management, medication adherence, and smoking cessation if applicable as part of potential lifestyle changes.
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