Clinical Notes
Clinical Notes 111
Montia McIntosh
NovaSoutheastern University
Health Assessment
NSG 5502
Dr. Marie Bova
Monday, April 1, 2013
Clinical Notes 111
Patient Initials: J.L.; Age: 64; Ethnicity: African-American; Gender: Male
Subjective:
Chief Compliant: 64 year old black male came in the office complaining of chest pain for 2 days. Patient verbalized that chest pain gets worst with activities and sometimes awakens him at night, especially whenever he sleeps on his right shoulder.
History of Present Illness: 64-year-old, well-nourished black male came in the office with chest pain for 2 days. Patient verbalized that he started having chest pain, especially when he is at work. He recently started a new job as a delivery driver where he is required to pick up and carry 50 pound boxes. He verbalized of generalized pain mostly in the chest area. He complains of pain 8 on a scale of 0-10. The pain is provoked with movement. Blood pressure was 154/90.
Past Medical History: Hypertension 2002, high cholesterol 2005, Benign Prostate Hypertrophy. Myocardial infarction with stent placement to left anterior descending artery in 1995 and right coronary artery in 2000.
Past Surgical History: Penile implantation 2011; appendectomy 1980.
Family History: Mother died at age 91 of Coronary Artery Disease. Mother had a history of diabetes, blindness, kidney disease that required dialysis for 14 years, and a myocardial infarction with coronary bypass graft, and uterine cancer. Father died at age 90 of prostate cancer. Father had a history of hypertension, diabetes, and open heart surgery. He has no other siblings. Paternal grandparents are deceased.
Social History: Patient is widowed with two children. He works as a delivery driver at a local gas company. He verbalized that he lives a sedentary lifestyle. Patient is a 50-year smoker. Patient denies alcohol and drug abuse.
Review of Systems:
General: He is a well-built, mildly overweight black male
Montia McIntosh
NovaSoutheastern University
Health Assessment
NSG 5502
Dr. Marie Bova
Monday, April 1, 2013
Clinical Notes 111
Patient Initials: J.L.; Age: 64; Ethnicity: African-American; Gender: Male
Subjective:
Chief Compliant: 64 year old black male came in the office complaining of chest pain for 2 days. Patient verbalized that chest pain gets worst with activities and sometimes awakens him at night, especially whenever he sleeps on his right shoulder.
History of Present Illness: 64-year-old, well-nourished black male came in the office with chest pain for 2 days. Patient verbalized that he started having chest pain, especially when he is at work. He recently started a new job as a delivery driver where he is required to pick up and carry 50 pound boxes. He verbalized of generalized pain mostly in the chest area. He complains of pain 8 on a scale of 0-10. The pain is provoked with movement. Blood pressure was 154/90.
Past Medical History: Hypertension 2002, high cholesterol 2005, Benign Prostate Hypertrophy. Myocardial infarction with stent placement to left anterior descending artery in 1995 and right coronary artery in 2000.
Past Surgical History: Penile implantation 2011; appendectomy 1980.
Family History: Mother died at age 91 of Coronary Artery Disease. Mother had a history of diabetes, blindness, kidney disease that required dialysis for 14 years, and a myocardial infarction with coronary bypass graft, and uterine cancer. Father died at age 90 of prostate cancer. Father had a history of hypertension, diabetes, and open heart surgery. He has no other siblings. Paternal grandparents are deceased.
Social History: Patient is widowed with two children. He works as a delivery driver at a local gas company. He verbalized that he lives a sedentary lifestyle. Patient is a 50-year smoker. Patient denies alcohol and drug abuse.
Review of Systems:
General: He is a well-built, mildly overweight black male
References: Family Practice Management AAFP-Coding (2012). Retrieved from http://www.aafp.org Medscape (2013). Retrieved from http://www.medscape.com Seidel, H., Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2011). Mosby’s guide to physical examination (7th ed.). St. Louis, MO: Mosby Elsevier. ISBN: 13-978-0-323-02888-2.