🩺 Record Detail
Patient Info
Transcript
<thead>
<tr>
<th><strong>Original Transcription</strong></th>
</tr>
</thead>
<tbody><tr><td id="fragmentid_1"><div><p><strong class="Patient">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 class="Doctor">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 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></tbody>
Clinical Notes
Patient Information - Patient Name: Not provided - Date of Birth: Not provided - Date of Visit: Not provided - Gender: Not provided - Patient ID: Not provided
Subjective - Patient complains of feeling a strange tightness in the chest for about three weeks, especially after climbing stairs or walking briskly. Describes it as uncomfortable, not sharp pain. Initially thought it was due to stress or fatigue but is occurring more frequently now. Reports the tightness is mostly in the center of the chest and usually resolves after a few moments. Also experiences quick shortness of breath and sometimes feels winded quickly.
Objective - No objective data provided.
Assessment - Suspected angina due to the description of chest tightness, especially with exertion, and associated symptoms like shortness of breath. Patient's history of high blood pressure and family history of heart disease increase the risk. Plan for further investigations including an ECG and stress test to evaluate cardiovascular health.
Plan - Further investigations: ECG and stress test to gain insights into cardiovascular health. - Lifestyle modifications: Emphasize a heart-healthy diet, stress management, medication compliance, and cessation of smoking if applicable. - Follow-up for treatment recommendations based on investigation results.