🩺 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: Patient DOB / Age: N/A Gender: N/A Medical Record # (MRN): N/A Date & Time of Encounter: SESSION_DATE Provider Name: DOCTOR_NAME
Chief Complaint (CC) Patient presents with: Feeling a strange tightness in the chest, especially after physical activities like climbing stairs or walking briskly. Describes it as uncomfortable, not sharp pain.
History of Present Illness (HPI) Onset: Three weeks ago Location: Mostly in the center of the chest Duration: Comes and goes, usually after physical activity Characteristics: Uncomfortable tightness Aggravating/Relieving Factors: Rest alleviates the symptoms Timing: After physical exertion Severity: Mild to moderate
Additional Notes: Symptoms started gradually and have been increasing in frequency.
Review of Systems (ROS) General: ☐ Fatigue ☐ Fever ☐ Weight Change ☐ Other: __ HEENT: ☐ Headache ☐ Vision Changes ☐ Sore Throat ☐ Other: _ Cardiovascular: ☐ Chest Pain ☐ Palpitations ☐ Other: Chest tightness Respiratory: ☐ Cough ☐ Shortness of Breath ☐ Other: _ Gastrointestinal: ☐ Nausea ☐ Vomiting ☐ Abdominal Pain ☐ Other: ___ Musculoskeletal: ☐ Joint Pain ☐ Muscle Weakness ☐ Other: _ Neurological: ☐ Dizziness ☐ Numbness ☐ Other: __ Psychiatric: ☐ Anxiety ☐ Depression ☐ Other: _____
Past Medical History (PMH) Conditions: High blood pressure Surgeries: N/A Allergies: N/A Medications: N/A
Physical Examination Vital Signs: BP: _ HR: Temp: _ RR: SpO₂: ____
General Appearance: N/A HEENT: N/A Cardiac: N/A Respiratory: N/A Abdominal: N/A Extremities: N/A Neurological: N/A
Assessment Primary Diagnosis: Possible angina due to reduced blood flow to the heart
Secondary Diagnoses: N/A
Plan Medications: To be determined Diagnostics/Labs Ordered: ECG, echocardiogram, stress test Procedures: N/A Referrals: N/A Follow-Up: Scheduled for test results review and further management. ADVISED to avoid heavy exertion.