Chief Complaint (CC): “Chest pain”
History of Present Illness (HPI): A 58-year-old Caucasian male, identified as P.D., visits the clinic with a primary concern of sporadic and intense chest pain. Within the last month, he reports three different occurrences of this symptomatology, each with a short episode. The patient later recognized that the discomfort he experienced might be due to heartburn. The patient assigns a score of 0 out of 10 to his current state of despair, with a possible maximum score of 5. The patient reports experiencing localized tightness and pain in the central chest region without any radiation to other body areas. The patient claims pain is relieved when immobile or at rest but worsens when they engage in physical activities like raking leaves or climbing stairs. Furthermore, he reported chest discomfort following episodes of overeating.
Location- the center of the chest.
Quality- uncomfortable and tense
Quantity or severity- 5/10 at worst.
Timing, including onset, duration, and frequency- three times every month, for a little period each time.
Setting in which it occurs- when undertaking yard upkeep at home.
Factors that have aggravated or relieved the symptom: Walking up the stairs aggravates his chest discomfort, which is alleviated when he sleeps.
Associated manifestations- Mild leg cramps as a result of moving
Medications: Lipitor once daily at a dosage of 20 milligrams; Lisinopril 20 mg once every day; 1200 mg of Omega-3 Fish Oil orally twice a day. Ibuprofen 200 mg, as needed, every four hours for the pain.
Allergies: He feels sick after taking codeine. Denies sensitivity to particular foods or environments.
Past Medical History (PMH):
Past Surgical History (PSH):
Sexual/Reproductive History: He has engaged in only one instance of sexual activity during his 27-year marriage.
Personal/Social History: The patient is a licensed professional engineer. He has been married to his wife for 27 years. The patient is a mother with a 19-year-old daughter and a 26-year-old son. He asserts having a family doctor even though he had not had an appointment with them for three months. The client refutes using illicit substances like marijuana, heroin, cocaine, or any combination. The individual consumes up to three beers during the weekends. He has ceased his regular bicycle riding. Upon obtaining approval from the physician, he intends to commence his exercise regimen. The patient engages in recreational fishing activities with his companion and sibling. The patient occasionally consumes fried food but maintains satisfactory health.
Immunization History:
Significant Family History:
Review of Systems:
Constitutional: denies experiencing fatigue and attributes a weight gain of 15-20 pounds to a lack of physical activity over the past few years. He also reports the absence of night sweats, fever, or chills.
HEENT: denies any alterations in visual acuity, throat discomfort, or swallowing difficulties.
Skin: denies having pallor and cyanosis
Respiratory: denies experiencing discomfort during inspiration and dyspnea.
Neurological: denies experiencing symptoms such as faintness, dizziness, numbness, or tingling in their extremities.
Cardiovascular: has ongoing chest pains, is unable to exercise because it makes the discomfort worse, denies palpitations, denies having ever had cyanosis or blood clots, and reports easy bleeding or bruising.
Gastrointestinal: deni
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