🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-09-20 12:48:08

Transcript

Doctor: OK, and where is the pain exactly? Patient: It's just right over on the on the left side. Doctor: OK, and when did this pain start? Patient: It started just 30 minutes ago. Doctor: OK, and did it just come on randomly or were you doing something strenuous? Patient: I was just juggling the driveway and it came on. Doctor: OK, and has that pain been getting worse at all over the last half an hour? Patient: 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. Doctor: 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? Patient: It feels dull. I feel like there's a lot of pressure on my chest. Doctor: 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? Patient: Uh, 7. Doctor: 7, OK. Have you had New York similar episodes before? Patient: No, I've never had any chest pain before. Doctor: 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? Patient: No, I'm kind of just feeling it right here. On the left side. Doctor: OK, uh, is there anything that you do that makes the pain either get worse or go away or like get better? Patient: 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. Doctor: OK, and does it change at all from you changing positions like if you're standing up versus sitting down or laying down? Patient: I think it's a little bit worse when I when I'm laying down. Doctor: 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? Patient: 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. Doctor: OK, and have you recently injured your chest or surrounding area at all? Like from a fall or anything like that? Patient: I do I play rugby and was tackled by another player yesterday. But but my chest felt fine after that. Doctor: OK, so but the pain just started half an hour ago. Patient: Yeah. Doctor: OK, have you have you been traveling at all recently? Patient: No, been at home. Doctor: OK, has anyone around you been sick at all? Patient: No. Doctor: OK, have you been having any symptoms like nausea or vomiting or any fevers or chills? Patient: No nausea or vomiting, but I do feel a little bit hot today. Doctor: OK, but have you measured your temperature at all? Patient: Uh, I did and it was 38 degrees. Doctor: OK, and have you been having any kind of swelling in your legs or feet? Patient: Uh, no swelling in my legs. Doctor: OK, have you been feeling tired at all, like increasingly fatigued? Patient: No, my energy has been good. Doctor: Have you been having any kind of thumping or palpitations or feel like your heart has been racing at all? Patient: It does feel like it's beating faster right now. It usually only feels like this when I'm playing sports. Doctor: OK. And have you noticed any changes in your skin at all? Any rashes? Patient: No rashes. Doctor: OK, have you had any cough or runny nose or sore throat? Any kind of those symptoms and in the past month? Patient: A few weeks ago I was a little runny, but that went away on its own. I haven't had any cough. Doctor: OK, and have you been feeling dizzy at all or have you fainted? Patient: No dizziness and uh no I haven't fainted at all. Doctor: OK. Just a few more questions. Have you had any diagnosis made by any physician or any anything like diabetes or high blood pressure? Patient: Yeah, I've been told I have high cholesterol and high blood pressure. Doctor: OK, and do you take any medications for the these things? Patient: Um, I do take medications for both blood pressure and cholesterol, rosuvastatin and umlicinopril and I take a multivitamin. Doctor: OK, and do you have any allergies to any medications at all? Patient: No allergies. Doctor: OK, have you at all in the past been hospitalized for any reason? Patient: No hospitalizations. Doctor: Any previous surgeries? Patient: No. Doctor: OK, and within your family, has anyone passed away from a heart attack or any cancers that run in the family? Patient: No. Doctor: OK, and currently right now, do you live alone? Do you live with someone? And where do you live, like an apartment or house? Patient: I live in a house with um, my parents. Doctor: OK, and do you currently work? Patient: Yeah, I drive a bus for the city. Doctor: OK, and in your daily routine, would you say you get enough exercise throughout the week? Patient: Uh yeah, usually on Sundays I'll go for a run. Doctor: OK, and how about your diet? Well, how's your diet like, just regularly? Patient: 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. Doctor: OK, and do you smoke cigarettes at all? Patient: I do yes. Been smoking for the last 20 years roughly. Doctor: OK, how much do you smoke on an average day? Patient: About a half a pack to a pack a day. Doctor: OK, and do you drink? Patient: No alcohol. Doctor: OK, and any recreational drugs like marijuana? Patient: Um, no marijuana, but I have used crystal meth in the past. Doctor: OK, and when was the last time that you used crystal meth? Patient: Um, six days ago. Doctor: Six days ago, OK, and how often do you use crystal meth? Patient: Um, I would say a couple of times a month. Doctor: A couple of times a month, OK. Alright, and for how long have you been using crystal meth? Patient: Uh for the last seven years. Doctor: Seven years, OK.

Clinical Notes

Dietitian Consult

Standardized Dietitian Consult Report

Patient Name: PATIENT_NAME

Date of Visit: SESSION_DATE

Chief Complaint (CC): Left-sided chest pain, pressure sensation, difficulty breathing.

Dietary History:

  • Typical Diet:
    • Breakfast: Not specified
    • Lunch: Not specified
    • Dinner: Not specified
    • Snacks: Eats out often, tries to eat as many vegetables as possible.
  • Fruit and Vegetable Intake: Attempts to eat as many vegetables as possible.
  • Processed Food Intake: Eats out often.
  • Water Intake: Not specified
  • Lactose Intolerance: Not specified

Medical History:

  • High Cholesterol: Managed with rosuvastatin.
  • High Blood Pressure: Managed with lisinopril.

Medications:

  • Rosuvastatin: For high cholesterol.
  • Lisinopril: For high blood pressure.
  • Multivitamin:

Allergies:

  • None: Reports no allergies to medications.

Social History:

  • Exercise: Goes for a run usually on Sundays.
  • Smoking: Smokes about half a pack to a pack a day for the last 20 years.
  • Alcohol: Does not drink alcohol.
  • Recreational Drugs: Used crystal meth a couple of times a month for the last seven years, last used six days ago.

Family History:

  • None: No family history of heart attack or cancers reported.

Review of Systems (ROS):

  • Constitutional: No fever, reports feeling hot with a temperature of 38 degrees.
  • Cardiovascular: Chest pain, pressure sensation, palpitations.
  • Respiratory: Difficulty breathing, no cough.
  • Gastrointestinal: No nausea or vomiting.
  • Neurological: No dizziness or fainting.
  • Skin: No rashes.
  • Other: No recent travel, no recent illness in contacts.

Nutritional Assessment:

  • BMI: [Insert BMI] (calculated based on weight and height provided).
  • BMI Category: [Insert BMI category] (e.g., overweight, obese).

Body Composition Analysis: Not performed during this visit.

Dietary Intake Analysis: To be completed based on a food diary for the next few days.

Nutritional Requirements: Not specified in the provided transcript.

Nutrition Diagnosis:

  • Inadequate Vegetable Intake: Attempts to eat as many vegetables as possible, but diet may be imbalanced due to frequent eating out.
  • Excessive Processed Food Intake: Eats out often.
  • Possible Nutrient Deficiencies: Potential for deficiencies due to inadequate intake of balanced diet.

Diet and Meal Planning:

  • Recommendations: Focus on increasing vegetable intake, reducing processed food consumption.

Nutritional Counseling:

  • Recommendations: Provide guidance on meal planning, portion control, and healthy food choices.

Nutritional Education:

  • Topics: Importance of balanced diet, the role of vegetables and whole grains in a healthy diet.

Specialized Diet Recommendations:

  • None: Not specified in the provided transcript.

Weight Management Strategies:

  • Recommendations: Encourage regular physical activity, at least 30 minutes of moderate-intensity exercise most days of the week. Prognosis: Good with adherence to recommended dietary and lifestyle changes.

Follow-up Plan:

  • Schedule: Follow-up appointment in a few weeks to discuss progress and address any concerns.

Patient Education:

  • Topics: Importance of a healthy diet, hydration, and regular physical activity for overall health and well-being.

Consultation Recommendations:

  • Food Diary Review: Review food diary upon completion to assess dietary intake and provide further personalized recommendations.

Referral Recommendations:

  • None: No referrals indicated at this time.
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