DCE Provider Notes - Focused Exam: Chest Pain, Brian Foster

Mr. Foster, a 58-year-old Caucasian male presents to the clinic and reports "I have been having some troubling chest pain in my chest now and then for the past month." Patient has a PMH of HTN and HLD. Patient describes the chest pain as tight, uncomfortable, non-radiating. Midsternal chest pain range is 5 out of 10 occurring X3 in the last month only a "couple of minutes." The last episode was three days ago. The first occurrence was with yard work, the second occurrence was after walking up four flights of stairs to bed, and the third occurrence was while out to a dinner with his wife. The pain is worsened and more noticeable with movement and is relieved by rest. He states that "It has never gotten really bad" so he did not think it was an emergency, but was concerned after the three episodes within one month and therefore, wants his heart checked, out. Last physical exam was 1 year ago but reports that he had not been checked out for several years before the first checkup. Reports thar his regular diet includes grilled meat, some sandwiches, and vegetables. He reports grilling between 4-5 times a week, often red meat. Reports to have fast foods for lunch. Denies coughing, dizziness, fatigue, weakness, nausea, vomiting, back pain, neck pain, and diarrhea. Denies chest pain at the time of interview. No history of depression. Past Medical History:  Hypertension- Stage II, diagnosed 1 year ago.  Hyperlipidemia- diagnosed 1 year ago  No surgical history  no hospitalization Surgical: Denies past surgeries This study source was downloaded by from CourseH on :47:36 GMT -05:00 Current Medications:  Metoprolol (Lopressor) 100mg PO daily  Lisinopril (Prinivil) 20mg PO daily  Atorvastatin (Lipitor) 20 mg PO Daily at bedtime, last dose 10pm yesterday.  Omega-3 Fish Oil 1200 mg PO BID, last dose 8am (OTC supplement)  OTC Tylenol as needed for aches and pains 3 to 4 times a month.  OTC Ibuprofen as needed for aches and pains 3 to 4 times a month. Allergies: Codeine experience nausea and vomiting Immunization:  Tdap in October 2014  Influenza vaccine this season Family History:  Father had hypertension, hyperlipidemia, obesity, and Died of colon cancer at the age of 75.  Mother is 80 years old, has Type II diabetes, hypertension  Brother died at the age 24 from motor vehicle accident  Sister is 52, has hypertension and Type II diabetes  Maternal grandmother died of breast cancer at the age of 65  Maternal grandfather died of heart attack at the age of 54  Paternal grandmother died of pneumonia at the age of 78  Paternal grandfather died of old age at the age of 85  Son is 26 and healthy  Daughter is 19 and asthmatic This study source was downloaded by from CourseH on :47:36 GMT -05:00 Social History:  Patient is an engineer, has two children 26 and 19.  Fluently speak English.  He never smoked, and reports drinking 2 -3 beer on the weekend.  Patient denies the use of marijuana, no cocaine or heroin or other  illicit drug.  Patient’s last visit to his primary physician is Dr. Melinda Smith was three month ago.  Patient last regular exercise was two years ago, has not been exercising due to his current chest pain.  However, he hopes to start exercising if clear by the provider.  Patient states he is conscious about his diet, monitor fat and sodium intake, also consumed steaks and burger once in a while. Review of Systems: General Survey: Patient alert, oriented. Appears well for his age. He denies chest pain at the moment. Denies headache, no lightheadedness, no syncope, no fever. HEENT: Head: Normocephalic and atraumatic. Eyes: Patient does not wear glasses. Ears: no concerns voiced. Nose: no abnormality. Throat: report no abnormality. Skin: Denies rashes, dry skin, itchiness or lesions. Cardiovascular: patient denies previous heart disease beside hypertension. Patient had a normal EKG three month ago. Respiratory: Patient denies shortness of breath. No coughing Gastrointestinal: denies nausea. Last bowel this morning, no concerns Integumentary: no concerns This study source was downloaded by from CourseH on :47:36 GMT -05:00 Neurological: denies headache, states he rarely experience headache Psychiatric: no abnormality noted Endocrine: no concerns voiced OBJECTIVE General Survey: Alert and oriented, with clear speech. Sitting comfortably in no acute distress. Vital Signs: BP: 146/90, SPO2: 98% in room air, Pulse: 104, Respiratory rate: 19, Temperature: 36.7, Height: 5’11, Weight: 197 lbs.. HEENT: Head: Normocephalic, symmetric facial features, atraumatic. No tenderness noted. Eyes: Visual acuity is intact. PERRLA. Ears: Hearing intact, TM is translucent and mobile. Nose: nasal mucosa is moist and pink. Throat: pharynx is pink with no exudate or swelling. Neck: Supple without adenopathy. The trachea is midline position. No thyroid tenderness or enlargement and no JVD noted. Skin: Skin is warm and dry, skin turgor no tenting, normal pigmentation. No clubbing noted on fingernails or toenails. Cardiac: S1, S2, without murmurs or rubs. S3 noted at mitral region. No swelling or fluid retention present. Peripheral Vascular: No JVD present. LJP present 3 cm above sternal angle. Left carotid with no bruit. Tight side carotid with bruit. Right carotid pulse with thrill, 3+. Brachial radial femoral pulses without thrill 2+. Popliteal tibial, and dorsalis pedis pulses without thrill, 1+. Capillary refill is 3 seconds in all 4 extremities. Respiratory: Breathing is quiet and unlabored. Breath sounds are clear to auscultation in upper lobes and RML. Fine crackles in posterior bases of L/R lungs.