Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System

Digital Clinical Experience Assessing the Heart, Lungs, and Peripheral Vascular System

SUBJECTIVE DATA:

Chief Complaint: “I have chest pain that has lasted about a month.”

History of Present Illness (HPI): Brian Foster is a 58-year-old male of Caucasian origin who presents to the clinic complaining of chest pain that has lasted about a month. The patient says that the pains make his chest feel tight, non-radiating, and uncomfortable. On a scale of 1-10, the patient rates the pain as five out of ten.

The says that his last episode of chest pain and tightness started three days ago. The first episode occurred when he was at work, the send while down the stairs to bed, and the third while having dinner with his wife. The says that the pain is aggravated when he moves and relieved when he is resting. The pain has never been worse and has not thought of it as an emergency. However, he was concerned when the pain occurred thrice in one month and that is why he came for a heart check-up. Other associated symptoms include pain in the jaws, fatigue, shortness of breath when episodes occur, and dizziness.

Medications: Atorvastatin (Lipitor) 20 mg PO Daily at bedtime, last dose 10 pm yesterday, Metoprolol (Lopressor) 100mg PO daily, Omega-3 Fish Oil 1200 mg PO BID last dose 8 am (OTC supplement), Lisinopril (Prinivil) 20mg PO daily, OTC Ibuprofen for pain management, OTC Tylenol for pain.

Allergies: He is allergic to Codeine. He experiences vomiting and nausea after taking Codeine.

Past Medical History (PMH): He was diagnosed with Hyperlipidemia and Hypertension- Stage II one year ago.

Past Surgical History (PSH): NO history of surgery.

Sexual/Reproductive History: Not Applicable.

Personal/Social History: Drinks 2 -3 beers on Sundays. Denies smoking or use of illicit drugs. He has two children aged 19 and 26. Exercised last two years ago but is conscious about his diet.

Immunization History: Received Influenza vaccine this season and Tdap on 2014 October.

Significant Family History: Father had obesity, HBP, and hyperlipidemia. He died at age 75 of colon cancer. The mother and sister have hypertension and type two diabetes. His maternal grandfather died at age 54 from a heart attack. His Maternal grandmother died at age 65 from breast cancer. His Paternal grandmother died at age 78 from pneumonia and his paternal grandfather died at age 85 of old age. His daughter is asthmatic at age 19.

Review of Systems 

• General: No weight loss, fever. Reports weakness.
• Cardiovascular/Peripheral Vascular:Denies previous heat problems.
• Respiratory: Denies previous respiratory issues. No cough.
• Gastrointestinal:No adnominal pain.
• Musculoskeletal:No joint or muscle pain.
• Psychiatric:No mental health diseases. Denies depression or anxiety.

OBJECTIVE DATA:

Physical Exam:

• Vital signs:P 104, BP 146/90, RR 19, Temp 36.4, SPO2: 98% in room air, Wt. 197lbs, Ht. 5’ 11.
• General: The patient is alert and o