🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2025-08-07 14:51:10

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

Clinical Notes:

  • Patient: Jhon
  • Date of Visit: SESSION_DATE
  • Presenting Complaint (CC): Patient complains of a strange tightness in the chest, especially after physical activity like climbing stairs or walking briskly. Describes it as uncomfortable, not sharp pain.

  • History of Present Illness (HPI): Jhon, a [age] year old female, reports experiencing chest tightness for about three weeks, initially attributing it to stress or fatigue. Symptoms have been increasing in frequency. Tightness is mostly centralized and alleviates after resting. Associated with quick onset of shortness of breath and occasional lightheadedness.

  • Review of Systems:

  • Constitutional: Chest tightness
  • Cardiovascular: Shortness of breath, lightheadedness

  • Physical Examination:

  • Cardiovascular: Pending ECG, echocardiogram, and stress test for further evaluation.

  • Past Medical History:

  • Hypertension

  • Family History:

  • Father: History of heart attack in his early 50s

  • Medications: Not specified

  • Allergies: Not reported

  • Investigations:

  • ECG, echocardiogram, and stress test pending

  • Labwork: None reported

  • Triage Information:

  • Vital signs: Not documented
  • Pain score: Not documented

  • Resuscitation and Stabilization Measures: None required

  • Time-Sensitive Interventions:

  • ECG, echocardiogram, and stress test

  • Consultations and Notifications:

  • Cardiology consult recommended

  • Critical Findings:

  • Pending investigations

  • Disposition:

  • Plan for further diagnostic tests

  • Follow-up Recommendations:

  • Lifestyle modifications, medication if necessary, and close follow-up for results interpretation and management.

  • Impression/Plan:

  • Suspected Cardiovascular Issue:
    • Plan: Perform ECG, echocardiogram, and stress test. Emphasize lifestyle changes, medication adherence, and regular follow-ups for optimal management. Early detection crucial for better prognosis.
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