Chief Complaint: Chest Pain

SUBJECTIVE
Chief Complaint: “l have been having some chest pain for the past month
HPI: Mr. Foster is a 58-year-old Caucasian man with hypertension and hyperlipidemia who presents to the clinic with complaints of chest pain now and then for the past month. He reports he thought it was heartburn. He said the first time he had chest pain was when he was doing yard work, and the second time was when he had to use the stairs at work. He reports that the chest pain feels tight and uncomfortable right in the middle of the chest. It has happened three times in the past month. The chest pain seems to get better within a minute. He rates pain 5/10, but right now, 0/10. The pain is relieved with a brief period of rest.
Medications:
Metoprolol (Lopressor) 100mg PO daily
Atorvastatin (Lipitor) 20mg PO daily at bedtime. Last dose 10pm yesterday (hyperlipidemia)
Omega-3 Fish Oil 1200mg PO BID last dose 8am (OTC supplement).
Tylenol or Ibuprofen as needed for pain
Allergies:
Codeine- nausea,and vomiting
Immunizations:
Tdap 10/2014
Influenza vaccine this season
PMH
Hypertension-Stage II diagnosed 1 year ago
Hyperlipidemia- diagnosed 1 year ago
No surgical history
Hospitalization:
None
Family History:
Father: hypertension, hyperlipidemia, obesity, died of colon, age 75
Mother: type 2 diabetes, hypertension, age 80
Brother: died age 24 in a motor vehicle accident
Sister: type 2 diabetes, hypertension, age 52
Maternal grandmother died of breast cancer age 65
Maternal grandfather died of a heart attack age 54
Paternal grandmother died of pneumonia
Son healthy age 26
Daughter asthma age 19
Social History
No past or present tobacco use
Reports dinking 2-3 alcoholic beverages (beer) per week
Denies the use of marijuana, cocaine, heroin or other illicit drugs
Review of Systems
Constitutional: No weakness, fatigue, fever, chills, or night sweats. Currently, weigh 97 pounds.
HEENT: Denies headache, vision, or hearing loss. Nonasal congestion, difficulty swallowing, lumps or neck stiffness
Skin: norashes, dryness, lesions, itches
Respiratory: Denies cough or shortness of breath
Cardiovascular: Denies heart palpation. Has chest tightness in the middle of the chest
Peripheral Vascular: Denies leg cramps or claudication
Gastrointestinal: Denies abdominal pain, dysphagia, dyspepsia, nausea, vomiting, diarrhea
Hematologic: Denies easy bruising, bleeding, or history of a blood clot, no prior blood transfusions
Neurological: Denies headaches, head injuries, lightheadedness,syncope, gait instability
Mental health: Denies stressed but feels anxious about not knowing what is going on in his chest.
OBJECTIVE
Physical Examination
General appearance: He is alert, awake and cooperative with the examination
Vital signs: T 36. 7C, RR 19, P 104, BP146/90, Sp02 98%, pain 0/10.
EKG: regular sinus rhythm, No ST changes
HEENT: Head is normocephalic Eyes:Pupils are equal in size. Sclera white. Ears: Hearing grossly intact. Nose patent bilate...