Focused Exam: Brian Foster- Chest Pain
Subjective
CC:
Patient reports having chest pain that is tight and uncomfortable.
HPI:
Patient reports that he experienced chest pain (CP) earlier this month. Patient reports that
the CP is in the middle of the chest and does not radiate. He reports that the pain is tight and
uncomfortable. Patient reports that the pain last a couple of minutes and is relieved with rest. He
reports having 3 episodes of CP this month with the last occurrence being on Friday. Patient
denies associated symptoms including nausea, vomiting, diaphoresis or palpitations when the CP
occurs. He denies ever having pain like this in the past. Denies current pain. Reports pain level
5/10 with 5 being the worst. Patient reports CP beings with physical activity which was noticed
when he was doing yard work and the second episode happened while walking up the stairs at
his job. Patient reports that sitting down to rest help to relieve the pain.
PMH:
1
.
HTN- diagnosed at 57
2. Hyperlipidemia- diagnosed at 57
Surgical: Denies past surgeries
Medications
:
1. Metoprolol (Lopressor) 100mg PO daily
2. Atorvastatin (Lipitor) 20 mg PO Daily at bedtime
3. Omega-3 Fish Oil 1200 mg PO BID
4. OTC Tylenol as needed for aches and pains 3 to 4 times a month.
5. OTC Ibuprofen as needed for aches and pains 3 to 4 times a month.
Allergies:
Codeine- Nausea and vomiting
Health Maintenance:
Tdap 10/2014, Influenza vaccination up to date. Reports getting
annual physicals. EKG performed three months ago with no abnormal findings. See Dr. Smith
