Sean 52yr old M
S: CC: chest pain 3 days ago
HPI: 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/ROS
Onset: 3 days ago
Location: chest
Duration: lasted 3 minutes
Characteristics: was short of breath, had heavy feeling in his chest, nauseous and sweaty
and tired.
Aggravating Factors: increased tiredness
Relieving Factors: went away on its own, has not happened again
Treatment: none
Severity: 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: NKDA
Immunizations: does not receive the flu shot
PMH:
Chickenpox as a child, hypertension, elevated cholesterol, (lifestyle management was
initiated.)
Surgical History:
T and A, cholecystectomy, vasectomy
Social 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 buddies
Family History:
Father (deceased)- HX of lung CA
Mother (deceased)- died from complications of a stroke
Brother (deceased)- died at age 44 from malignant melanoma.
Other brothers and sisters are healthy.
ROS:
CONSTITUTIONAL: -fever. - chills. (+) sweaty.
HEENT: - Dizziness, (-) headaches, - changes in vision, - ear pain, (-) nasal drainage, -
sore throat.
CARDIOVASCULAR: (+) chest pain, (+) palpations, - edema lower extremities.
