Clinical Notes

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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 who is awake, alert, and pleasantly engaged in conversation. No active distress noted.

Skin/Hair/Nails: No excoriation or secondary infection. Tugor resilient, no edema. No redness, no exudates, no swelling, no tenderness.

Head and Neck: No pain, lumps, swelling, or neck stiffness. Patient denies pain with range of motion neck (Seidel, Ball, Dains, Flynn, Solomon, & Stewart, 2011).

Eyes: Vision 20/20 with glasses, no nyastymus, no ptosis, eyes symmetric, no discharge, discomfort or redness.

Ears/Nose/Throat: No pain, discharge, tinnitus, hearing loss, halitosis, no discharge or polyps.

Lymph: No complaints of swollen lymph noted.

Chest and Lungs: No pain on respiration, no wheezing or cough. Patient denies night sweats and shortness of breath.

Breast and Axillae: Patient denies tenderness, discharge, or lump. No gynecomastia.

Heart and Blood Vessel: Patient complains of chest pain with activity.

Peripheral Vasculature: No claudication, no tendency to bruise easily.

Hematology: Denies anemia, no blood cell disorder.

GI: No nausea and vomiting, regular bowels, no black tarry stools, no hemorrhoids. Patient complains of indigestion when he eats late at night.

Diet: Regular diet with sedentary lifestyle.

Endocrine: No thyroid enlargement, no intolerance to heat or cold, no unexplained weight loss.

GU: No dysuria. Patient complains of occasional nocturia.

Musculoskeletal: Patient complains of chest pain with movement, twisting and turning.

Mental/Neurological: Denies tremors, seizures or syncopal episodes (Seidel et al., 2011).

Objective:

Oral temp 98.6; BP 154/90; HR 118; RR 16; Pain 7/10, headache; Ht. 6’2; Wt. 220.

General: No acute distress, well groomed.

Skin: Warm dry intact, dispersed freckles to face, chest and back, no bruises, no rashes, no palpable masses, no jaundice or pallor. Cap refill < 3 seconds, no clubbing or cyanosis.

Head: Erect and midline, skull norm cephalic,...
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