Doctor: Good morning Mr. Smith, I’m Dr. Lee. What brings you in today? Patient: Morning doctor. I’ve been getting a squeezing sensation in my chest for the last two weeks whenever I walk up the stairs or go for a short jog. It usually eases when I rest. Doctor: Can you describe the pain more? Does it radiate anywhere? Patient: It feels like pressure right behind my breastbone, sometimes into my left shoulder. No shortness of breath at rest, but I do feel a little winded when it happens. Doctor: Any other symptoms—nausea, sweating, dizziness? Patient: I’ve been a bit sweaty and a little lightheaded at times, but no vomiting. Doctor: Do you have any medical history we should know about? Patient: I have high blood pressure and high cholesterol. I take lisinopril and atorvastatin. No history of diabetes. Doctor: Family history of heart disease? Patient: My father had a heart attack at 62. My mother has hypertension. Doctor: Do you smoke or drink alcohol? Patient: I used to smoke a pack a day for 20 years, quit five years ago. I have a glass of wine with dinner most nights. Doctor: Let’s check your vitals and listen to your heart. Nurse: Blood pressure is 150 over 90, heart rate 88, respiratory rate 16, temperature 98.4, oxygen saturation 98 percent on room air. Doctor (after exam): Your heart sounds are normal, no murmurs, no leg swelling. I’d like to get an electrocardiogram and check some blood markers. We’ll also schedule a stress test. Patient: Okay. What might be causing this? Doctor: It could be angina from blockages in your coronary arteries given your risk factors. We’ll start you on a low-dose aspirin and a short-acting nitroglycerin as needed. We’ll review your ECG and blood tests before planning the stress test.

Chief_Complaint: main reason for today’s visit History_: { HPI: details of present illness including onset character and triggers PMH_: past medical history relevant to cardiology FH_: family history of cardiovascular disease SH_: social history including tobacco and alcohol use } Vital_Signs: { Blood_Pressure: recorded blood pressure Heart_Rate: recorded heart rate Respiratory_Rate: recorded respiratory rate Temperature_: recorded temperature Oxygen_Saturation_: recorded oxygen saturation } Cardiovascular_Exam: { Heart_Sounds: description of heart sounds and any murmurs Peripheral_Edema_: presence or absence of lower extremity edema } Diagnostics_: [ Name: diagnostic test or lab Results: findings or values Notes_: any additional comments ] Assessment_and_Plan: { Diagnoses: [ ICD_10: diagnosis code Condition: name of cardiac condition Notes_: supporting details ] Medications: [ Name: medication name Dosage: strength or amount Frequency: dosing schedule Route_: route of administration Notes_: special instructions or precautions ] Procedures_: recommended or scheduled procedures Recommendations_: lifestyle modifications and risk factor management Follow_up: plan for follow-up visits or tests }