🩺 Record Detail
Patient Info
Transcript
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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="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="Patient">Patient</strong>: I have high blood pressure and my father had a heart attack in his early 50s.</p></div></td></tr><tr><td id="fragmentid_10"><div><p><strong class="Doctor">Doctor</strong>: That increases your risk. We'll need to perform an ECG, echocardiogram, and a stress test. These will give us insights into your heart's performance.</p></div></td></tr><tr><td id="fragmentid_11"><div><p><strong class="Patient">Patient</strong>: Is it serious?</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong class="Doctor">Doctor</strong>: It could be. But the good news is, early diagnosis leads to better outcomes. Depending on the results, we might need medication or lifestyle changes.</p></div></td></tr><tr><td id="fragmentid_13"><div><p><strong class="Patient">Patient</strong>: What kind of lifestyle changes?</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong class="Doctor">Doctor</strong>: A heart-healthy diet, regular light exercise, stress management, and medication compliance. Also, no smoking if applicable.</p></div></td></tr><tr><td id="fragmentid_15"><div><p><strong class="Patient">Patient</strong>: I don't smoke. But I do need to improve my diet and activity levels.</p></div></td></tr><tr><td id="fragmentid_16"><div><p><strong class="Doctor">Doctor</strong>: That's a good start. We'll schedule the tests and review everything together. In the meantime, avoid heavy exertion.</p></div></td></tr><tr><td id="fragmentid_17"><div><p><strong class="Patient">Patient</strong>: Thank you, Dr.. I appreciate the care.</p></div></td></tr><tr><td id="fragmentid_18"><div><p><strong class="Doctor">Doctor</strong>: You're welcome. We'll take good care of you.</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, especially after physical activity.
History of Present Illness (HPI): • Onset: Three weeks ago • Duration: Persistent • Location: Center of the chest • Quality: Uncomfortable • Severity: Not mentioned • Timing: Relieved by rest • Associated Symptoms: Shortness of breath, light-headedness • Aggravating/Relieving Factors: Physical activity • 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: Non-smoker • Occupation: Not mentioned • Living Situation: Not mentioned
Review of Systems (ROS): • General: Not mentioned • ENT: Not mentioned • Respiratory: Not mentioned • GI: Not mentioned • 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: Suspected angina • Secondary Diagnosis (if any): Not mentioned
Plan: • Investigations: ECG, echocardiogram, stress test • Medications Prescribed: Not mentioned • Supportive Care: Lifestyle modifications, stress management • Referral: Not mentioned • Follow-Up: Scheduled for test review and further management.