🩺 Record Detail

Patient Info

Name: Unknown

Age: Unknown

Date: 2025-08-04 10:08:50

Transcript

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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Stethoscope emoji, Dr. Patient Conversation, Cardiovascular</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Patient, Good Morning, Dr. I've been feeling a strange tightness in my chest lately,</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> after climbing stairs or walking briskly. It's not sharp pain, but it's</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Dr. Good Morning. I'm glad you came in. Chest tightness can be an</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> conditions, including cardiovascular How long has this</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Patient, for about three weeks now. At first, I thought it was stress or fatigue,</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> happening more often now. Dr., is the tightness located in the center of</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> one side? Patient, mostly in the center. It usually goes away after a few</p></div></td></tr><tr><td id="fragmentid_9"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Dr., that could be angina, which is due to reduced blood flow to the heart. Any shortness</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><tr><td id="fragmentid_19"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> But I do need to improve my diet and activity levels. Dr., that's a good start.</p></div></td></tr><tr><td id="fragmentid_20"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> the tests and review everything together. In the meantime, avoid</p></div></td></tr><tr><td id="fragmentid_21"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Patient, thank you, Dr.. I appreciate the care. Dr., you're welcome. We'll take</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 tightness is now more frequent. The patient experiences shortness of breath and gets winded quickly. The chest tightness is mostly located in the center and tends to resolve after a few moments.

Objective:

Patient has a history of high blood pressure.
Family history of heart disease in the father's early 50s.
No other significant findings noted during the consultation.

Assessment:

Possible angina due to reduced blood flow to the heart, considering the symptoms of chest tightness, shortness of breath, and the patient's medical history of high blood pressure. Increased risk due to family history of heart disease.

Plan:

Perform an ECG and a stress test to assess the cardiovascular status.
Depending on the test results, consider medication or lifestyle modifications.
Emphasize the importance of lifestyle changes, including a heart-healthy diet, stress management, medication compliance, and smoking cessation if applicable.
Schedule a follow-up appointment to discuss test results and further management options.

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