🩺 Record Detail
Patient Info
Transcript
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<tbody><tr><td id="fragmentid_1"><div><p><strong>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>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>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>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>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>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>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>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>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>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>Patient</strong>: Is it serious?</p></div></td></tr><tr><td id="fragmentid_12"><div><p><strong>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>Patient</strong>: What kind of lifestyle changes?</p></div></td></tr><tr><td id="fragmentid_14"><div><p><strong>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>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>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="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, especially after physical activity like climbing stairs or walking briskly. Describes it as uncomfortable, not sharp pain.
History of Present Illness (HPI): • Onset: Three weeks ago • Duration: Increasing frequency • Location: Mostly in the center of the chest • Quality: Uncomfortable • Severity: Not specified • Timing: Relieved after resting • Associated Symptoms: Shortness of breath, light-headedness • Aggravating/Relieving Factors: Physical activity • Previous episodes: Not specified • Medications tried: Not specified • Recent Travel / Sick Contacts / Exposure: Not mentioned
Past Medical History (PMH): • Chronic Conditions: High blood pressure • Past Surgeries/Hospitalizations: None reported • Allergies: Not mentioned • Current Medications: Not mentioned
Social History: • Smoking / Alcohol / Drug Use: Denies smoking • Occupation: Not mentioned • Living Situation: Not mentioned
Review of Systems (ROS): • General: Not specified • ENT: Not specified • Respiratory: Not specified • GI: Not specified • Others as relevant: Not specified
Physical Examination (PE): • Vital Signs: Temp: °C, HR: __ bpm, BP: /, RR: , SpO₂: __% • General Appearance: Not assessed • HEENT: Not assessed • Chest/Lungs: Not assessed • Cardiovascular: Not assessed • Abdomen: Not assessed • Neurological: Not assessed • Skin: Not assessed
Assessment: • Primary Diagnosis: Suspected angina • Secondary Diagnosis (if any): To be determined
Plan: • Investigations: ECG, echocardiogram, stress test • Medications Prescribed: Not prescribed during the visit • Supportive Care: Lifestyle modifications - heart-healthy diet, light exercise, stress management • Referral: None • Follow-Up: Scheduled for test results review and further management. Avoid heavy exertion in the meantime.