History and Physical Informant: Patient, who is AOX3 and old chart.

History and Physical

Informant: Patient, who is AOX3 and old chart.

Chief Complaint: This is 64 year old Hispanic male with PMH of hypertension and dyslipidemia present to the clinic with chest discomfort. Patient stated that chest discomfort is in the middle of his chest and it feels like a burning sensation along with tingling.

History of Present Illness: Mr. JG. is a 64-year old male with a history of HTN and dyslipidemia present to the clinic with chest discomfort for past two month. Patient stated that chest discomfort is in the middle of his chest and it feels like a burning sensation along with tingling. Patient rated his pain 5 out of 10. Patient also stated that mostly happen when I am doing activity like climbing stairs however sometime it does happen when I am just watching TV. Patient denies any episodes of felling dizzy or passing out. Patient denied radiation of the pain to neck or jaw. He took Advil and it is not doing anything. Patient is non-compliance with his cholesterol medication.

 

Current Regimen: Lisinopril 5 mg daily

Hydrochlorothiazide 25 mg daily

 

Past Health General: Hernia repain 2002, Last mammogram 2004, colonoscopy 1997, relatively good health otherwise.

 

ROS: General: has slowly gain weight over last ten years, denies weakness, , fevers, memory changes, nervousness, anxiety,depression, suicide.

Skin: no rash, lumps, sores, itching, dryness, color change, change in hair/nails, bruising or bleeding, excessive sweating, heat or cold intolerance.

Head: Denies headache, head injury, dizziness.

Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred

vision, or blindness.

Ears: no hearing change, tinnitus, infection, discharge.

Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.

Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago.

Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.

Neuro: No syncope, seizures, weakness, paralysis, numbness, tremors, or involuntary

movements.

Pulmonary: Dyspnea with activity, negative hemoptysis, wheezing, pleuritic pain

Neuro: No headache dizziness, focal numbness/weakness, nausea, vomiting.

Cardiac : See HPI.

MS: no muscle, joint pain, or joint stiffness, positive for chest pain

GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain,

belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food

intolerance, indigestion, nausea, vomiting, early fullness, odynophagia.

GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria,

nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids.

 

Social History: Patient has never smoked. She drinks alcohol rarely, does not use recreational drugs and is monogamous in a married relationship for many years. She has two grown children and works as a secretary. She does not exercise on a regular basis. Dietary history was not detailed but she did admit to eating “quite a bit of fast food.

 

 

Family History: Her father died of a heart attack at age 58. Mother is alive and in relatively good health. One sister has Hypertension & adult-type diabetes.

Physical Exam 1. Vital Signs: temperature 98.2 Pulse 94 regular with occasional extra beat, respiration 20, blood pressure 158/92

2. Generally a well developed, slightly obese, .

3. HEENT: Eyes: extraocular motions full, gross visual fields full to confrontation, conjunctiva clear. sclerae non-icteric, pulpils equal round and reactive to light and accomodation, fundi not well visualized due to possible presence of cataracts. Ears: Hearing very poor bilaterally. Tympanic membrane landmarks well visualized. Nose: No discharge, no obstruction, septum not deviated. Mouth: Complete set of upper and lower dentures. Pharynx not injected, no exudates. Uvula moves up in midline. Normal gag reflex.

4. Neck: jugular venous pressure 8cm, thyroid not palpable. No masses.

5. Nodes: No adenopathy

6. Chest: Breasts: atrophic and symmetric, non-tender, no masses or discharges. Lungs: diminished lung sound, No dullness to percussion. Diaphragm moves well with respiration. No rhonchi, wheezes or rubs.

7. Heart: PMI at the 6th ICS, 1 cm lateral to MCL. No heaves or thrills. Regular rhythm with occasional extra beat. Normal S1, S2 narrowly split; Pulses are notable for sharp carotid upstrokes. Pulses: Carotid brachial radial femoral +2

8. Spine: mild kyphosis, mobile, nontender, no costovertebral tenderness

9. Abdomen: soft, flat, bowel sounds present, no bruits. Nontender to palpation. Liver edge, spleen, kidney not felt. No masses. Liver span 10cm by percussion.

10. Extremities: skin warm and smooth except for chronic venous stasis changes in both legs. 1+ edema to the knees, non-pitting and very tender to palpation. No clubbing nor cyanosis. 11.Neurological: Awake, alert and fully oriented. Cranial nerves III-XII intact except for decreased hearing. Motor: Strength not tested, patient moves all extremities. Sensory: Grossly normal to touch and pin prick. Cerebellar: no tremor nor dysmetria. Reflexes symmetrical 1+ through out, no Babinski sign.

12. Pelvic: deferred until patient more stable.

13. Rectal: Prominent external hemorrhoid, No masses felt. Stool brown, negative for blood

Labs: Troponin negative times 2, CBC and CMP WNL.

CXR portable AP, probable cardiomegaly, mild PVC

Impression

Because patiet’s discomfort has been present for two months, seems to follow a relatively predictable pattern, and has not worsened in severity, frequency, or occurred at rest, her chest pain, if angina, would be characterized as stable angina.

Plan: 1. Resting EKG

2. Stress Test

3. Coronary Angiogram

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History and Physical Informant: Patient, who is AOX3 and old chart. was first posted on October 12, 2020 at 12:41 pm.
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