Chief complaint: “I have been having some trouble with chest pain for the past month
History of presenting illness: Mr. Foster presents at the emergency department complaining of chest pain in the mid-sternum region. It is intermittent, tight, and uncomfortable lasting for a short time. It is of acute onset aggravated by meals and exertion and relieved by rest. However, the pain does not radiate. It is associated with mild leg cramping the patient denies coughing, shortness of breath, indigestion, heartburn, jaw pain, dizziness weakness, nausea, vomiting, diarrhea, anxiety, and emotional stress.
Past medical history: the patient has hypertension, hyperlipidemia, and diabetes mellitus
Surgical history: none
Allergies: he is allergic to dust, fur, and cold weather. He develops a skin rash and itchiness and relieves it by taking prednisolone. He has no food and drug allergy.
Medication: metformin 1g PO BID, amlodipine 10mg PO OD, atorvastatin 20mg PO OD
Immunization: the patient’s immunization schedule is up to date. His last influenza and pneumococcal vaccines are six months and three months ago respectively. He is yet to get a tetanus toxoid booster.
Social history: Mr. foster works as an operations manager in a bank. She has studied up to a master’s degree in finance. He is married, has two children, and stays with them. He enjoys reading novels and watching documentaries. His diet includes grilled red meat about five times a week, vegetables, and sandwiches. Occasionally, he takes fast food for lunch on a busy day with 1-2cups of coffee a day. He smokes at least cigarettes per day. He takes two bottles of beer daily and a bottle of whisky over the weekend. He does not engage in physical exercise.
Family history: the patient is the firstborn in a family of three siblings. His mother has hyperlipidemia, hypertension, and osteoarthritis. His father has obesity, diabetes mellitus, coronary heart disease, and hypertension. His paternal grandfather died six years ago due to acute myocardial infarction and his grandmother died ten years ago due to diabetes mellitus. His maternal grandparents are living with senile dementia. His younger sister 40 years has hypertension. His younger brother, 35years old has hyperlipidemia and diabetes mellitus. His children have no major chronic illnesses. However, there is no history of lung or breast cancer.
General: the patient denies fatigue, weight loss, night sweats, and fever.
HEENT: The patient denies headache, dizziness, eye itchiness, ear pain, sore throat, and running nose.
Respiratory system: the patient denies coughing, running nose, difficulties in breathing, wheezing, and sputum production.
Gastrointestinal system: the patient denies abdominal pain, reflux, heartburn, nausea, vomiting, diarrhea, constipation, and Malena stool.
Genitourinary system: the patient denies hematuria, dysuria, polyuria, flank pain, vaginal discharge, dyspareunia, and urine incontinence.
Neurological: the patient denies paralysis, numbness of extremities, facial droop, and tingling sensation.
Musculoskeletal system: the patient reports mild cramping of the legs. However, he denies joint pain, muscle pain, stiffness, muscle spam, fracture, and dislocation.
Hematological system: the patient denies easy bruising, frequent infections, fever, and bleeding tendencies.
Lymphatic system: the patient denies lower limb edema, recurring infections, skin fibrosis, and lymph nodes.
Skin: the patient denies skin rash, stretch marks, and itchiness.
Endocrine: patient denies weight fluctuation, weakness, fatigue, heat and cold intolerance, and mood swings.
General examination: the patient is alert and oriented. he has a clear speech sitting comfortably with no acute distress.
Vitals: blood pressure 164/88, pulse rate 94beats per minute, the temperature at 36.5, height 151cm, weight 78kg, and BMI 34.21kg/m2.
Cardiovascular system:
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