SUBJECTIVE DATA: Mr. Brian Foster is a 58 years old male who presented at the emergency department with complaints of acute chest pain at the mid-sternum of the chest. The pain is tight and uncomfortable, aggravated by movement up the stairs and exertion. The pain is relieved by rest. The chest pain is periodic and lasts a few minutes. He has had three episodes of pain in one month. He denies coughing, shortness of breath, indigestion, fatigue, dizziness, weakness, nausea, vomiting, heartburn, orthopnea, and syncope.
Chief Complaint (CC): “I’ve been experiencing this tight, uncomfortable feeling in my chest every now and then. I’m starting to worry it could be something serious.”
History of Present Illness (HPI): Brian Foster is a 58-year-old Caucasian male who came in for chest pain, which occurred three times in the past month. He reports that the pain is right in the middle of the chest, over the heart, and does not radiate. He describes the pain as tight and uncomfortable, with a pain scale of 5 out of 10. But currently, he is not experiencing any pain. He states that the pain started earlier this month when he was doing his yard work. The pain has a sudden onset, and is aggravated by physical activities such as yard work and taking stairs, and relieved by brief rest such as lying still. He denied taking any medications for the chest pain. According to him, the pain is not related to any food consumption nor stress. The pain usually lasts a couple of minutes.
Medications: Lisinopril (Prinivil) 20mg PO Daily, high blood pressure. Atorvastatin (Lipitor) 20mg PO daily at bedtime, hyperlipidemia . Omega-3-Fish Oil 1200mg PO BID. Tylenol and Ibuprofen for pain as needed.
Allergies: Codeine- Nausea and vomiting
Past Medical History (PMH): Hypertension -Diagnosed a year ago. Hyperlipidemia- a year ago
Past Surgical History (PSH): No past surgical history noted
Sexual/Reproductive History: Married to wife for 27 years. Has 2 children
Personal/Social History: Lives at home with wife and daughter visits frequently. Patient currently works as a civil engineer. Denies tobacco use. Denies marijuana, cocaine, heroin, or other illicit drug use. Reports social drinking 2-3 alcoholic beverages of beer per week. Reports eating three meals a day Patient reports generally low stress lifestyle. Denies regular exercise routine currently. Last regular exercise was two years ago. Reports seeing healthcare providers every 6 months. Last visit was roughly 3 months ago. Has a primary care doctor. Has no financial issues.
Immunization History: Tdap 10/2014, Flu vaccine received for the season
Significant Family History:
Mother: type 2 diabetes, hypertension, age 80
Brother: died age 24 in motor vehicle accident
Sister: type 2 diabetes, hypertension, age 52
Maternal grandfather: died of heart attack, age 54
Maternal grandmother: died of breast cancer, age 65
Paternal grandmother: died of pneumonia, age 78
Paternal grandfather: died of old age at 85
Son: healthy, age 26
Daughter: asthma, age 19
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