🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-01 04:22:21

Transcript

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                                                   <th><strong>Original Transcription</strong></th>
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                                             <tbody><tr><td id="fragmentid_1"><div><p><strong>Doctor</strong>: Okay, and where is the pain exactly?</p></div></td></tr><tr><td id="fragmentid_2"><div><p><strong>Patient</strong>: It's just right over on the left side.</p></div></td></tr><tr><td id="fragmentid_3"><div><p><strong>Doctor</strong>: Okay, and when did this pain start?</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong>Patient</strong>: It started just 30 minutes ago.</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong>Doctor</strong>: Okay, 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>Patient</strong>: I was just juggling the driveway and it came on.</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong>Doctor</strong>: Okay, 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>Patient</strong>: No, it just came on suddenly and it's a, 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="SPEAKER-01">SPEAKER-01:</strong> P, no, it just came on suddenly and it's a,</p></div></td></tr><tr><td id="fragmentid_10"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Yeah, the pain has been there this whole time</div></td></tr><tr><td id="fragmentid_11"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: and it's gotten worse ever since it started.</div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and how</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Is it kind of like an aching pain or is it a sharp or tight tightness</p></div></td></tr><tr><td id="fragmentid_14"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: How would you describe it?</div></td></tr><tr><td id="fragmentid_15"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, it feels dull.</div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I feel like there's a lot of pressure on</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, and how do you rate the pain right now on a scale</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> 0 being the least amount of pain you felt</p></div></td></tr><tr><td id="fragmentid_19"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: 10 being the worst.</div></td></tr><tr><td id="fragmentid_20"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, uh, 7.</div></td></tr><tr><td id="fragmentid_21"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: D, 7, okay.</div></td></tr><tr><td id="fragmentid_22"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Have you had New York similar episodes</p></div></td></tr><tr><td id="fragmentid_23"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, no, I've never had</p></div></td></tr><tr><td id="fragmentid_24"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and is the pain just staying in the region of the left chest area that you mentioned or is it traveling to</p></div></td></tr><tr><td id="fragmentid_25"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, no, I'm kind of</p></div></td></tr><tr><td id="fragmentid_26"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> On the left side, D, okay, uh, is there anything that you do that makes the pain either get worse</p></div></td></tr><tr><td id="fragmentid_27"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, uh, I think it's a bit bit worse if I'm moving around or when</p></div></td></tr><tr><td id="fragmentid_28"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I think it made it a bit worse, but nothing has seemed to make it any better</p></div></td></tr><tr><td id="fragmentid_29"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and does it change at all from you changing positions like if you're standing up</p></div></td></tr><tr><td id="fragmentid_30"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, I think it's a little bit worse when I'm laying</p></div></td></tr><tr><td id="fragmentid_31"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and other than the</p></div></td></tr><tr><td id="fragmentid_32"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> have you been having any other symptoms like a cough or difficulty breathing or any pain when</p></div></td></tr><tr><td id="fragmentid_33"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, uh, I felt a little bit assured of breath or having difficulty breathing since yesterday when the sorry since the</p></div></td></tr><tr><td id="fragmentid_34"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: but adjust the difficulty breathing.</div></td></tr><tr><td id="fragmentid_35"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and have you recently injured</p></div></td></tr><tr><td id="fragmentid_36"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Like from a fall or anything like that?</div></td></tr><tr><td id="fragmentid_37"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> I do I play rugby and was tackled by another player</p></div></td></tr><tr><td id="fragmentid_38"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: But but my chest felt fine after that.</div></td></tr><tr><td id="fragmentid_39"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay so but the pain just started half an</p></div></td></tr><tr><td id="fragmentid_40"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, yeah.</div></td></tr><tr><td id="fragmentid_41"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, have you been</p></div></td></tr><tr><td id="fragmentid_42"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no, been at home.</div></td></tr><tr><td id="fragmentid_43"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, has anyone around you been</p></div></td></tr><tr><td id="fragmentid_44"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no.</div></td></tr><tr><td id="fragmentid_45"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> okay, have you been having any symptoms like nausea or vomiting or</p></div></td></tr><tr><td id="fragmentid_46"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, no nausea or vomiting, but I do</p></div></td></tr><tr><td id="fragmentid_47"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, but have you measured your temperature</p></div></td></tr><tr><td id="fragmentid_48"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, but I did and it was 38 degrees.</div></td></tr><tr><td id="fragmentid_49"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and have you been having any kind of</p></div></td></tr><tr><td id="fragmentid_50"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no swelling in my legs.</div></td></tr><tr><td id="fragmentid_51"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, have you been feeling tired at all,</p></div></td></tr><tr><td id="fragmentid_52"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no, my energy has been good.</div></td></tr><tr><td id="fragmentid_53"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, have you been having any kind of thumping or palpitations or feel like your heart has been</p></div></td></tr><tr><td id="fragmentid_54"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, it all hit does feel like it's beating faster right</p></div></td></tr><tr><td id="fragmentid_55"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> It usually only feels</p></div></td></tr><tr><td id="fragmentid_56"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and have you noticed any</p></div></td></tr><tr><td id="fragmentid_57"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Any rashes?</div></td></tr><tr><td id="fragmentid_58"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no rashes.</div></td></tr><tr><td id="fragmentid_59"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, have you had any cough or runny nose</p></div></td></tr><tr><td id="fragmentid_60"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Any kind of those symptoms and in the past</p></div></td></tr><tr><td id="fragmentid_61"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, a few weeks ago I was a little runny, but that went</p></div></td></tr><tr><td id="fragmentid_62"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: I haven't had any cough.</div></td></tr><tr><td id="fragmentid_63"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and have you been feeling dizzy at all or</p></div></td></tr><tr><td id="fragmentid_64"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, no dizziness and unknown</p></div></td></tr><tr><td id="fragmentid_65"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, just</p></div></td></tr><tr><td id="fragmentid_66"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> Have you had any diagnosis made by any physician or anything like diabetes or high blood</p></div></td></tr><tr><td id="fragmentid_67"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, yeah, I've been told I have high cholesterol and high</p></div></td></tr><tr><td id="fragmentid_68"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> okay, and do you take any medications</p></div></td></tr><tr><td id="fragmentid_69"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> P, um, I do take medications for both blood</p></div></td></tr><tr><td id="fragmentid_70"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> rosyavastatin, and umlisynapril and I take a</p></div></td></tr><tr><td id="fragmentid_71"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and do you have any allergies to any</p></div></td></tr><tr><td id="fragmentid_72"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no allergies.</div></td></tr><tr><td id="fragmentid_73"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, have you had all in the past been hospitalized</p></div></td></tr><tr><td id="fragmentid_74"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no hospitalizations.</div></td></tr><tr><td id="fragmentid_75"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: D, any previous surgeries?</div></td></tr><tr><td id="fragmentid_76"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no.</div></td></tr><tr><td id="fragmentid_77"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and within your family has anyone passed away from a heart attack or any</p></div></td></tr><tr><td id="fragmentid_78"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: P, no.</div></td></tr><tr><td id="fragmentid_79"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> D, okay, and currently right now,</p></div></td></tr><tr><td id="fragmentid_80"><div><i class="fas fa-user"></i> <span class="mic"></span> <span class="speaker">Identifying</span>: Do you live with someone?</div></td></tr><tr><td id="fragmentid_81"><div><p><strong class="SPEAKER-01">SPEAKER-01:</strong> And where do you live, like an</p></div></td></tr></tbody>

Clinical Notes

SOAP Note

Subjective:

The patient reports pain on the left side of the chest that started suddenly 30 minutes ago while juggling. The pain has been constant and has worsened since onset. The patient describes the pain as dull and feels pressure. The current pain level is rated at 7 out of 10. The patient denies similar previous episodes and mentions that movement exacerbates the pain. There is no relief with changing positions. The patient also reports feeling short of breath since yesterday. No recent injuries are reported.

Objective:

  • Temperature: 38 degrees Celsius
  • Medications: Rosuvastatin and Lisinopril for high cholesterol and blood pressure, respectively
  • No swelling in the legs
  • No rashes
  • No cough or runny nose currently
  • No dizziness
  • No allergies
  • No hospitalizations or surgeries
  • Family history negative for heart attacks
  • Living situation not specified

Assessment:

  1. Acute chest pain on the left side, possibly musculoskeletal in nature.
  2. Shortness of breath, possibly related to the chest pain.
  3. High cholesterol and hypertension managed with Rosuvastatin and Lisinopril.

Plan:

  1. Further evaluation to rule out cardiac issues.
  2. Consider imaging or ECG if deemed necessary.
  3. Monitor for any changes in symptoms.
  4. Follow up with primary care physician for review and management of high cholesterol and hypertension.
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