Note - Chest Pain Focused Exam

Note - Chest Pain Focused Exam ID: 58-year-old, Caucasian male; new patient with private insurance; reliable historian, seen June 22, 2022, at 11:30 am. CC: “…troubling chest pain in my chest now and then for the past month” Subjective: HPI: Patient presents to the clinic today stating that he has been having sporadic chest pain with exertion such as yard work or taking the stairs, and with overeating. He has had 3 episodes of pain over the past month. He describes the pain as “tight and uncomfortable right in the middle of my chest” with each episode lasting “several minutes”. He denies crushing, gnawing, or burning pain. He reports that the pain does not radiate, he denies arm, should, or neck pain. He reports that at worst the severity of pain is a 5/10, and he currently denies having any pain, a 0/10. He denies any worsening pain with eating, spicy foods, or high-fat foods. He reports that the pain goes away with rest, and he denies taking any medication for the pain. Denies angina diagnosis, coronary artery disease, or diabetes. Heart auscultation – S1, S2, S3 noted over mitral area. No JVD, right sided carotid bruit with right carotid pulse 3+ with thrill. No left sided bruit. Radial, brachial, femoral pulses without thrill 1+. Cap refill <3 seconds in bilateral upper and lower extremities. PMH: - Hypertension Stage II - dx 2021 - Hyperlipidemia - dx 2021 PSH: None Medications: - Lisinopril 20 mg, once daily - Atorvastatin 20 mg, once daily at bedtime, started one year ago - Fish oil - Occasional Ibuprofen, PRN Allergies: - Codeine – nausea and vomiting Social Hx: Reports that he has 2-3 alcoholic drinks a week, on the weekends. Denies and problems with alcohol. Denies illicit drug use, or any tobacco use. Patient is an engineer. Patient is a heterosexual male, sexually active with wife for 27 years. Denies any elevated stress. Denies any regular exercise, last regular exercise was two years ago. Immunizations: Patient reports that he is “all up to date”. Family History: Maternal grandfather died young of a heart attack. 1 Screenings: - EKG – normal - Stress test – normal, done within past two years Nutrition: - Breakfast - granola bar and instant breakfast shake - Lunch – turkey sub - Dinner – grilled meat and vegetables - Denies salt intake, soda drinking Mental health: No unusual stress, anxious about chest pain ROS: Review of System Constitutional: Denies fever, chills, unintentional weight loss, dizziness, or palpations. Respiratory: Bilateral, posterior lower lobes fine crackles auscultated. Clear, vesicular bilateral breath sounds anteriorly, and upper posterior lobes. No cough, SOB, wheezing. No pain with inspiration. CV/PV: see HPI GI: Soft, round, non-tender. Tympanic upon percussion throughout. Liver at 7cm MCL and 1cm below RCM. Bilateral kidneys and spleen not palpable. Denies heartburn or GERD. Neuro: AOX4, active full range of motion upper and lower bilaterally. Clear speech, cognition intact. Objective: BP: 146/90 right arm, 146/88 left arm P: 104, regular RR: 19 Temp: 36.7 C SpO2: 98% on RA General: Well nourished, well developed, appearing stated age, in no acute distress Diagnostics: EKG: normal sinus rhythm, no ST elevation Assessment: 1. Coronary artery disease with stable angina Diff Dx: 2. Pericarditis (Acute onset angina) 3. Myocardial Infarction (Angina) 4. Pneumonia (Angina, fine crackles auscultated) 5. GERD (Angina) 2 6. (Chronic) Essential HTN Plan: Diagnostics: EKG, Chest xray, echocardiogram, exercise stress test. Labs: CBC, ABG, Troponin, BNP, CMP Therapeutics: Propranolol 80 mg, once daily in the morning. Restart leisurely bike riding after exercise stress test and after starting propranolol, try to walk or ride bike for 30 minutes a day. Eat more multi-colored vegetables with lunch and dinner. Education: Do not abruptly stop taking propranolol, can cause tachycardia, hypertension, monitor heart rate and do not take medication if below 60. Get up from sitting or lying position slowly and deliberately to avoid dizziness or falls. Follow-up: Follow up in 2 weeks after labs, and stress test. Call 911 or go to hospital if experiencing shortness of breath, increased chest pain that is not relieved with rest. Referral: Begin seeing a cardiologist Signature: Paul Challan RN [TYPED signature] 3