COURSE:
NGR 6002C: Advanced Health Assessment and Diagnostic
CC: “I’m having Chest Pain”
HPI: A 68-year-old AA female complains of central chest pressure, with radiation up to the throat on and off x 3 days. She thought it was related to something that she ate so she took tums, but the symptoms have not stopped. The pain is more intense at night when she lies down to sleep. She is having acid reflux, but denies nausea, vomiting, or abdominal pain. No diaphoresis or dyspnea. She does not recall trauma or injury. She cannot associate the chest pain with activity. She had a similar type of pain approximately a month ago but that time it resolved with tums and an over the counter Pepcid. She is a little worried because this time it has not resolved.
PMH: HTN x 10 years
PSH: Cholecystectomy 6 years ago
Medications: Amlodipine 5mg, hydrochlorothiazide (HCTZ) 12.5mg daily and a daily multi-vitamin.
Allergies: Penicillin (Hives). Denies food, latex, or environmental allergies.
Family History: Unknown: adopted
Social History:
Lives with husband in a 3-bedroom house and feels that it is a safe neighborhood. Children are all grown and do not live at home. Works full time as a bookkeeper in an accountant’s office. Denies smoking tobacco (now or ever). Drinks socially 1-2 cocktails per month. Denies drug use or marijuana. No recent travel
Sexual & Reproductive History: OB/GYN: G4, P4. LMP: Post-menopausal
REVIEW OF SYSTEMS:
General – Denies fever, chills, fatigue, weakness, weight loss, night sweats, or changes in sleeping patterns.
Skin – Denies rashes, abrasions, itching or dryness.
HEENT – Denies ear pain, denies nasal congestion, sinus pressure or pain. Denies sore throat or dysphagia. Has noticed occasional hoarseness and an occasional cough. No sputum.
Neck – denies pain or swollen glands.
Respiratory – Denies orthopnea, cough, wheezing, or shortness of breath.
Cardiovascular – Chest pressure, with radiation up to the throat on and off x 3 days. Occasional palpitations, usually when lying down to sleep at night. No history of murmur.
Gastrointestinal – Recent indigestion symptoms for a week or two, but still has a good appetite. Denies abdominal pain, nausea, or vomiting. Denies constipation or diarrhea. Moves bowels daily
Genitourinary – Denies frequency, urgency, dysuria, hematuria, or incontinence.
Peripheral vascular – denies leg cramps or edema
Musculoskeletal – denies arthralgia or myalgia or limited range of motion.
Neurological – denies syncope, weakness, seizures, or paresthesia
Psychological – Denies depression or anxiety.
NGR6002C
Spring 2020
OBJECTIVE/PHYSICAL EXAM FINDINGS:
Vital signs: BP: 148/88, Temperature: 98.6, Pulse: 80, Respirations: 14. Height: 5’2, Weight: 165.
General: Appearance, behavior, and speech are appropriate.
Skin: Warm and dry, natural color, no rashes, lesions, or abrasions. Nails without cyanosis
HEENT: PERRL, TM’s intact, pearly grey, Nares pink, no erythema. Throat: Oral mucosa pink,
Neck: No lymphadenopathy. No thyromegaly. No audible carotid bruits.
Lungs: bilateral breath sounds equal and clear, no wheezing.
Cardiovascular: RRR S1 and S2, No S3 or S4 gallop. Mild systolic murmur most audible over left lower sternal border (LLSB) III/VI. No pain to chest wall with palpation. Pulses +2 throughout. No peripheral edema. No bruits.
Abdomen: flat, soft, non-tender. Bowel sounds active x 4, no rebound tenderness, no hepatosplenomegaly. No bruits.
Musculoskeletal: Full range of motion without limitations
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