Patient Information:
L.M., 60-year-old male, African American, insurance unknown.
(S) Subjective:
CC: chest pain three days ago
HPI:
"My wife made me
... [Show More] come, I feel fine." Three days ago, Larry M. felt short of breath, had this heavy feeling in his chest, and he got kind of nauseous and sweaty. It lasted only about 3 minutes, and it has not happened again, but he does feel a little more tired. "It could be that I have not worked out since it
happened."
Current Medications:
None
Allergies: NKDA
PMHx: Reports general health as good. He Had been feeling great since starting to work out and lost weight. Had lots of energy and felt great until this episode three days ago. Now he is a little concerned because he feels a little more tired when he works out. He has not done as much strenuous running and has not worked out since the episode. Hypertension- lifestyle changes recommended. Elevated cholesterol, lifestyle management was initiated.
PSHx: T and A, cholecystectomy, vasectomy.
Childhood Illnesses: chicken pox. Immunization Hx: Refuses flu shot. Other Screenings: Not reported.
Soc Hx: Married for 20 years, works as an architect. Enjoys a beer or a glass of whiskey and the
occasional cigar when playing poker with his buddies.
Fam Hx: Parents are deceased. Father had lung cancer and mother died from complications of a stroke.
Brother died at 44 from malignant melanoma. Another sister and brother are healthy.
ROS:
CONSTITUTIONAL: No reports of fever, chills. Reports planned weight loss. Reports increased fatigue
starting 3 days ago.
HEENT: None reported.
SKIN: None reported.
CARDIOVASCULAR: Reports shortness of breath, chest heaviness, nausea and sweating. RESPIRATORY: Shortness of breath 3 days ago, none since. Denies sputum.
GASTROINTESTINAL: Nausea 3 days ago. GENITOURINARY: None reported.
NEUROLOGICAL: None reported. MUSCULOSKELETAL: None reported. HEMATOLOGIC/LYMPHATICS: None reported. PSYCHIATRIC: None reported.
ENDOCRINOLOGIC: None reported. ALLERGIES: None reported.
O:
Vital signs: B/P 146/90, HR 70, Sao2 97% RA. Height 5’”, weight 220 pounds
BMI: 33.5 PHYSICAL EXAM
GENERAL: African American male in NAD. Alert, oriented, and cooperative. Pain: 0/10 at present.
HEENT: African American male in NAD. Alert, oriented, and cooperative. Pain: 0/10 at present. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. No AV nicking noted. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus non-tender. Nose: Nares patent without exudate. Sinuses non-tender to palpation, Right-sided Deviation. Throat: Oropharynx moist, no lesions or exudate. Teeth in poor repair, gums reddened and receding, filled cavities noted. Tongue smooth, pink, no lesions, protrudes in midline. Neck supple. No cervical lymphadenopathy or tenderness noted.
Thyroid midline, small and firm without palpable masses. Mild JVD in recumbent position [Show Less]