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 CC: Troubling chest pain in my chest   Subjective HPI : Brian…

 CC: Troubling chest pain in my chest

 

Subjective

HPI: Brian Foster 58yr old Caucasian male c/o chest pain a month ago rate of pain is 5/10 with no associated factors. Lying still helps with pain. Pain happens after physical activity. Then stops a couple of minutes later. Pain once after dinner with the wife. No edema was noted. No respiratory. No gastrointestinal issues. Denies rheumatic fever. compliant with meds. Denies headaches, and dizziness. 

 

Vitals:146/90 104HR, 109mmHg, 19RR, 36.7(O),98%

MEDS: Lisinopril (Prinivil) 

20 mg PO

Atorvastatin (Lipitor)

20 mg PO

Omega-3 Fish Oil, 

 

FH: Father: Deceased, age 75. Died of colon cancer. Hypertension, hyperlipidemia, obesity.

Mother: Still living, age 80. Type 2 diabetes, hypertension.

Paternal grandmother: Deceased. Died of pneumonia, at age 78.

Paternal grandfather Deceased. Died of “Old age”, age 85.

Maternal grandmother: Deceased. Died of breast cancer, at age 65.

Maternal grandfather: Deceased. Died of a heart attack, at age 54.

Brother: Deceased. Died of a motor vehicle accident, at age 24.

Sister: Still living, age 53. Hypertension, type 2 diabetes.

Married: Wife still living.

Son: Still living, age 26 Healthy Daughter: Still living, age 19. Asthma.

 

Social: Reports employment at Civil Engineering Firm here in town for 40 years. Report degree in Civil Engineering. Reports being married for 27 years and having two children. Reports hobbies of doing small electronic repairs and attending son’s building competition. Reports religion affiliation of “Loosely Lutheran”. Reports living at home with wife. Denies stress. Reports fishing as a coping mechanism. Reports wife, children, and close friends as the biggest support system. Denies regularly exercising. Report riding a 

 

OBJECTIVE:

Bruit in right carotid no thrill 3+ palpated. S1 S2 S3 in right and left lower posterior lobes with Gallop. PMI: displaced laterally brisk and tapping less than 5cm. Abdomen round. Liver payable to 1cm below the right costal margin.

Diagnostic: EKG: No ST elevation, regular sinus rhythm 

CC: Troubling chest pain in my chest”

 

Include any pertinent labs, x-rays, or diagnostic tests that would be appropriate to support the differential diagnoses mentioned. Differential Diagnoses (list a minimum of 5 differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list (#1) 

 

Please list references so I can research further.

 

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