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Sean 52yr old MS: CC: chest pain 3 days agoHPI: Sean is a 52-year-old male with a history of HTN who comes into the clinic about a chest pain he had 3 days ago. He reports that his lisinopril was stopped 3 months ago. He also reports elevated cholesterol level on his last visit, but id currently managing condition through diet and exercises and other lifestyle changes. Sean reports of chest pain began 3days ago. He felt short of breath, got sweaty, nauseated with symptoms lasting about 3 mins. Although he reports that he has lost weight but he says that he is more concerned now because he feels increasing tiredness when he works. OLDCART/ROSOnset: 3 days agoLocation: chestDuration: lasted 3 minutesCharacteristics: was short of breath, had heavy feeling in his chest, nauseous and sweaty and tired.Aggravating Factors: increased tirednessRelieving Factors: went away on its own, has not happened againTreatment: noneSeverity: has had to shorten his workouts since the episode due to lack of energy.Is the pain in a specific area or more generalized? Does it radiate to back, shoulder, and jaw? Does the pain spread to your neck and arms? How and when did the pain start? Did something specific seem to trigger the pain? (food, activity?). Does it start gradually and build up or start suddenly? How long did it last?Have you lost weight recently? What are your typical workouts or recreational activities?Have you recently made changes to your exercise routine? How much do you exercise?
Did the symptoms occur after your work- out or in certain environments?Have you been diagnosed with elevated cholesterol or coronary heat disease?Do you have a family history of heart disease, heart attack, HTN, hyperlipidemia, sudden cardiac death? Any previous diagnosis of heart burn, GERD in the past?What order medications do you take? What is your diet like? Do you smoke? How many pack/day? How much do you drink? What dietary supplements or herbal medications do you take?Current Medications: none. Lisinopril stopped 3 months ago.Allergies: NKDAImmunizations: does not receive the flu shotPMH:Chickenpox as a child, hypertension, elevated cholesterol, (lifestyle management was initiated.)Surgical History:T and A, cholecystectomy, vasectomySocial History:Married for 20 years, works as a mortgage broker at a local bank. Enjoys a beer or a glass of Jameson and the occasional cigar when playing poker with his buddiesFamily History:Father (deceased)- HX of lung CAMother (deceased)- died from complications of a strokeBrother (deceased)- died at age 44 from malignant melanoma.Other brothers and sisters are healthy.