🩺 Record Detail
Patient Info
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<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="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 mentioned • Date of Birth: Not mentioned • Date of Visit: Not mentioned • Gender: Not mentioned • Patient ID: Not mentioned
Chief Complaint (CC): Patient complains of chest tightness for the past three weeks.
History of Present Illness (HPI): • Onset: Three weeks ago • Duration: Persistent • Location: Mostly in the center of the chest • Quality: Not sharp, uncomfortable • Severity: Not mentioned • Timing: Intermittent, usually goes away after a few moments • Associated Symptoms: Shortness of breath, getting winded quickly, nausea • Aggravating/Relieving Factors: Not mentioned • Previous episodes: Not mentioned • Medications tried: Not mentioned • Recent Travel / Sick Contacts / Exposure: Not mentioned
Past Medical History (PMH): • Chronic Conditions: High blood pressure • Past Surgeries/Hospitalizations: Not mentioned • Allergies: Not mentioned • Current Medications: Not mentioned
Social History: • Smoking / Alcohol / Drug Use: Not mentioned • Occupation: Not mentioned • Living Situation: Not mentioned
Review of Systems (ROS): • General: Not mentioned • ENT: Not mentioned • Respiratory: Shortness of breath • GI: Nausea • Others as relevant: Not mentioned
Physical Examination (PE): • Vital Signs: Temp: °C, HR: __ bpm, BP: /, RR: , SpO₂: __% • General Appearance: Not mentioned • HEENT: Not mentioned • Chest/Lungs: Not mentioned • Cardiovascular: Not mentioned • Abdomen: Not mentioned • Neurological: Not mentioned • Skin: Not mentioned
Assessment: • Primary Diagnosis: Angina • Secondary Diagnosis (if any): Not mentioned
Plan: • Investigations: ECG, stress test • Medications Prescribed: Not mentioned • Supportive Care: Heart-healthy diet, stress management, medication compliance • Referral: Not mentioned • Follow-Up: Not mentioned