🩺 Record Detail
Patient Info
Transcript
[00:00 → 00:05] Stethoscope emoji, Dr. Patient Conversation, Cardiovascular Concern [00:05 → 00:13] Patient, Good Morning, Dr. I've been feeling a strange tightness in my chest lately, especially [00:13 → 00:19] after climbing stairs or walking briskly. It's not sharp pain, but it's uncomfortable. [00:19 → 00:26] Dr. Good Morning. I'm glad you came in. Chest tightness can be an early sign of several [00:26 → 00:32] conditions, including cardiovascular issues. How long has this been happening? [00:32 → 00:37] Patient, for about three weeks now. At first, I thought it was stress or fatigue, but [00:37 → 00:43] it's happening more often now. Dr., is the tightness located in the center [00:43 → 00:49] of your chest or on one side? Patient, mostly in the center. It usually goes away [00:49 → 00:55] after a few minutes of rest. Dr., that could be angina, which is due to reduced blood [00:55 → 01:03] flow to the heart. Any shortness of breath, nausea, or disease? Patient, yes, I do get [01:03 → 01:09] winded quickly and sometimes feel light-headed. Dr., do you have any medical history, like [01:09 → 01:16] high blood pressure, diabetes, or a family history of heart disease? Patient, I have high [01:16 → 01:22] blood pressure and my father had a heart attack in his early fifties. Dr., that increases [01:22 → 01:29] your risk. We'll need to perform an ECG, echocardiogram, and a stress test. These will [01:29 → 01:37] give us insights into your heart's performance. Patient, is it serious? Dr., it could be. [01:37 → 01:43] But the good news is, early diagnosis leads to better outcomes. Depending on the results, [01:43 → 01:50] we might need medication or lifestyle changes. Patient, what kind of lifestyle changes? [01:50 → 01:58] Dr., a heart-healthy diet, regular light exercise, stress management, and medication compliance. [01:58 → 02:05] Also, no smoking if applicable. Patient, I don't smoke. But I do need to improve my diet [02:05 → 02:12] and activity levels. Dr., that's a good start. We'll schedule the tests and review everything [02:12 → 02:19] together. In the meantime, avoid heavy exertion. Patient, thank you, doctor. I appreciate [02:19 → 02:24] the care. Dr., you're welcome. We'll take good care of you.
Clinical Notes
Subjective
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Patient: Reports feeling a strange tightness in the chest for about three weeks, especially after physical activities like climbing stairs or walking briskly. Describes the sensation as uncomfortable, not sharp pain.
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Location: Tightness mostly in the center of the chest, which usually subsides after resting for a few minutes.
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Associated Symptoms: Experiences quick shortness of breath, occasional lightheadedness.
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Past Medical History:
- High blood pressure.
- Family history of heart disease - father had a heart attack in his early fifties.
Objective
- No specific objective data provided.
Assessment
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Angina: Suspected due to the presentation of chest tightness, especially with physical exertion, and associated symptoms like shortness of breath and lightheadedness.
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Cardiovascular Risk:
- Patient's history of high blood pressure and family history of heart disease increase the risk of cardiovascular issues.
Plan
- Diagnostics:
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Order an ECG, echocardiogram, and stress test to evaluate heart function and assess for any underlying cardiovascular conditions.
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Lifestyle Modifications:
- Advise heart-healthy diet modifications.
- Recommend regular light exercise.
- Suggest stress management techniques.
- Emphasize medication compliance.
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Encourage cessation of smoking if applicable.
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Follow-Up:
- Schedule a follow-up to review test results and discuss further management based on the findings.
- Instruct the patient to avoid heavy exertion until further evaluation is completed.