Omar Tarek Hassan
عمر طارق حسنMRN: MRN-2026-001001Encounter: ENC-2026-000001 (OPD)38 Years • Male • Blood: A+ • Phone: +201012345678 • National ID: 28805140102345
Critical Allergies:⚠️ Penicillin (LIFE_THREATENING)⚠️ NSAIDs (Ibuprofen) (MODERATE)
1. Chief Complaint & Subjective (S)
Chest tightness, elevated systolic BP (145/95 mmHg), shortness of breath on exertion.
History of Present Illness (HPI):
Patient reports progressive retrosternal heaviness over the past 2 weeks, exacerbated during brisk walking. No radiation to neck or jaw. No dizziness or syncope.
2. Objective Physical Examination (O)
General: Conscious, alert, oriented x3. CVS: S1+S2 audible, regular rhythm, no murmur. Chest: Clear bilaterally, vesicular breath sounds. Abdomen: Soft, lax, non-tender.
3. Assessment & Treatment Plan (A/P)
1. Order 12-lead ECG and 2D-Echocardiogram. 2. Prescribe Amlodipine 5mg OD po. 3. Low-sodium diet counseling and moderate walking.
Follow-Up Plan: Return for clinical review with ECG results in 7 days.