History
Full Name: Mr. CD
Address: Queens, NY
Date of Birth: 3/27/1971
Date & Time: May 4, 2021 9:21 am
Location: NYPQ, Flushing, NY
Religion: —
Source of Information: Self
Reliability: Reliable
Source of Referral: Primary Care Physician
Chief Complaint: “sharp pain in my chest” x 3 months
History of Present Illness:
50-year-old male, non-smoker, COVID status negative with PMH of BPH, hyperlipidemia, appendicitis c/o sharp pain in his chest x 2 years, with an increase in occurrence and severity of episodes x 3 months. Pain ranges from “tingling” to “sharp” in the precordium, is brought about by exertion, does not radiate, lasts several minutes, and is relieved by rest. The chest pain is occasionally accompanied by shortness of breath in episodes exacerbated by duress. Patient rates the pain a 6/10 and has taken no medications to relieve symptoms. Patient received a stress test 1 week prior with findings of a “blockage at the bottom of my heart”. Patient denies palpitations, irregular heartbeats, edema, dizziness, weakness, syncope, dyspnea, orthopnea, fatigue, weakness, hemoptysis, leg pain, or edema. Patient has expressed an increase in work-related stress the previous year with worsening of frequency and severity of chest pains.
Past Medical History
HLD x 20 years – noncompliant with medications
BPH – last prostate exam 2 months prior with findings of enlarged prostate – noncompliant with medications
Appendicitis – 5 years ago with subsequent appendectomy
Stress Test – 1 week ago with finding of occlusion of coronary artery unspecified by the patient
Past Surgical History
Appendectomy – 5 years ago
Surgical removal of cyst on right upper thorax – 15 years ago
Medications
Aspirin – 81 mg tablet PO daily
Denies herbal medications and supplements
Allergies:
NKDA
Family History
Mother – Deceased 2016 – CAD, HTN
Father – Deceased 2011 – CAD, HTN
Social History:
Mr. CD is a 50 y/o male, single, with 4 children
Habits – never drinker, no tobacco use ever, drinks herbal tea occasionally
Travel – denies recent travel
Diet – explains his food choices “could be better” and expresses desire to adopt a healthier diet
Exercise – denies any exercise activity
Sleep patterns – averages 5 hours of sleep per night
Sexual history – active, heterosexual, denies history of STI
Review of Systems:
General – Denies loss of appetite, recent weight loss or gain, weakness/fatigue, fever or chills, or night sweats
Skin, Hair, Nails – denies discolorations, moles/rashes, changes in hair distribution, excess dryness or sweating, pruritus or changes in texture.
Head – Denies headaches, dizziness, vertigo, or head trauma
Eyes – He utilizes prescription glasses as needed for driving. Does not remember date of last eye exam. Denies lacrimation, pruritus, visual disturbances, or photophobia.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids
Nose/Sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/Throat – Denies sore throat, sore tongue, bleeding gums, ulcers, or use of dentures. Does not recall last dental exam.
Neck – Denies localized swelling/lumps, stiffness, or decreased range of motion
Breast – Denies lumps, nipple discharge, or pain
Pulmonary System – Occasional SOB induced by stress, denies cough, wheezing, hemoptysis
Cardiovascular System – Patient has episodes of chest pain, denies irregular heartbeat, edema/swelling of ankles or feet, syncope
Gastrointestinal System – Denies change in appetite, nausea/vomiting, abdominal pain, diarrhea, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, jaundice, hemorrhoids, rectal bleeding or blood in stool.
Genitourinary System – Patient has Hx of BPH with his last prostate exam 6 months ago. Denies urinary urgency, oliguria, dysuria, incontinence, or flank pain.
Nervous – Denies memory impairment, seizures, headache, LOC, ataxia, weakness, change in cognition/ mental status.
Musculoskeletal System – Denies any other muscle/joint pain, deformity, swelling, redness.
Peripheral Vascular System – Denies varicose veins, peripheral edema, color changes, coldness, intermittent claudication
Hematological system – Denies anemia, bruising or bleeding, history of DVT/PE, blood transfusion, or lymph node enlargement
Endocrine system – He denies nocturia, polyuria, polyphagia, excessive sweating, hirsutism, goiter, or heat/cold intolerance
Psychiatric – Denies depression/sadness, anxiety, OCD or ever having seen a mental health professional
Physical:
Vital Signs: BP: R L
106/70 108/70
RR: 18/min, unlabored P: 66, regular
T: 36.8 C O2 Sat: 99% Room air
Height: 66 inches Weight: 160 lbs.
General: Male of medium build, neatly groomed, appearance appropriate for age.
Head, Hair, & Skin
Skin: warm & moist, good turgor. Non-icteric, no lesions noted, no scars, tattoos
Hair: average quantity and distribution
Nails: no clubbing, capillary refill <2 seconds in upper and lower extremities
Head: normocephalic, atraumatic, non-tender to palpation throughout
Ear, Nose, & Sinus:
Ear: Symmetrical and appropriate in size. No trauma/lesions/masses on external ears. No foreign bodies or discharge in the external auditory canals AU. TM’s pearly white / intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC>BC AU.
Nose: Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.
Sinuses: Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Eyes:
Eyes are symmetrical OU. No ptosis, exophthalmos or strabismus.
Conjunctiva moist and pink, Sclera are white, and cornea is clear.
Visual acuity uncorrected – 20/30 OS, 20/30 OD, 20/30 OU
PERRLA, EOMs intact with no nystagmus, visual fields full OU.
Fundoscopy. Red reflex is intact OU. Cup to disk ratio <0.5 OU. No AV nicking, hemorrhages, exudates or neovascularization OU
Neck: Trachea is midline. No lesions, scars, masses, or pulsations noted. Supple, non-tender to
palpation. FROM, no stridor is noted. 2+ Carotid pulses, no thrills/ bruits noted bilaterally, no cervical adenopathy noted.
Thyroid: Non-tender, no palpable masses, no thyromegaly, no bruits noted.
Thorax & Lungs:
Chest: Symmetrical, no trauma, no deformities. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Transverse to AP diameter 2:1. Non-tender to palpation throughout.
Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Cardiac:
Heart: PMI in 5th ICS in midclavicular line. Carotid pulses are 2+ bilat, no bruits noted. Rate and rhythm regular (RRR). Distinct S1 and S2 without murmurs, no S3 or S4. No friction rub or split S2 appreciated
Abdomen:
Abdomen is symmetric and flat with no striae, scars, or pulsations. Bowel sounds are normoactive in all 4 quadrants with no aortic / renal /iliac or femoral bruits. Non-tender to palpation with tympany throughout, no guarding or rebound tenderness noted. No hepatosplenomegaly on palpation, no CVA tenderness was appreciated
