🩺 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="Patient">Patient</strong>: For about three weeks now. At first, I thought it was stress or fatigue, but it's happening more often now.</p></div></td></tr><tr><td id="fragmentid_4"><div><p><strong class="Doctor">Doctor</strong>: Is the tightness located in the center of your chest or on one side?</p></div></td></tr><tr><td id="fragmentid_5"><div><p><strong class="Patient">Patient</strong>: Mostly in the center. It usually goes away after a few minutes of rest.</p></div></td></tr><tr><td id="fragmentid_6"><div><p><strong class="Doctor">Doctor</strong>: That could be angina, which is due to reduced blood flow to the heart. Any shortness of breath, nausea, or dizziness?</p></div></td></tr><tr><td id="fragmentid_7"><div><p><strong class="Patient">Patient</strong>: Yes, I do get winded quickly and sometimes feel light-headed.</p></div></td></tr><tr><td id="fragmentid_8"><div><p><strong class="Doctor">Doctor</strong>: Do you have any medical history, like high blood pressure, diabetes, or a family history of heart disease?</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 mentioned - Date of Birth: Not mentioned - Patient ID: 123456 - Gender: Not mentioned - Contact Number: (123) 456-7890 - Address: Not mentioned
Medical History - Previous Diagnoses: Not mentioned - Surgeries: Not mentioned - Allergies: Not mentioned - Current Medications: Not mentioned - Family Medical History: Father had heart disease in his early 50s.
Current Visit - Reason for Visit: Patient experiencing chest tightness, shortness of breath, and lightheadedness.
Vital Signs - Blood Pressure: Not measured - Heart Rate: Not measured - Temperature: Not measured - Respiratory Rate: Not measured - Weight: Not measured - Height: Not measured
Physical Examination - Findings suggestive of angina due to reduced blood flow to the heart. - Patient to undergo ECG and stress test for further evaluation. - Lifestyle changes recommended include a heart-healthy diet, stress management, medication compliance, and no smoking.