Biological Data
S.J- Male- 8/18/1960 – 55 - Caucasian – Married – Italian – English- Christian- teacher- College- heterosexual - 6’2 – 197 – 25….. John (son) 347-999-9999 –
Reason for seeking Healthcare – pt c/o chest tightness and SOB when patient walk upstairs, or during exercise.
Current health status
C- Tightness of chest, indigestion, chest pain, SOB, Sweating
O- On going for the past 4 years
L- Central chest but can radiate to L shoulder.
D- 3-5 minutes, several times feels like 7 minutes. About 5 times this month. Only once this week.
S- It forces him to stop what he doing and sit down.
P- It feels better when he sits down and rest for a bit. Take a couple deep breath and drink some water. When I move around too much, his chest starts to get tight, so he have to slow down his activity or completely stop.
A – Patient complains of SOB, and sweating. Sometimes Random dizziness and light-headedness when changing positions.
Current Medications- Aspirin 500 MG, transdermal Nitroglycerin patch 0.6mg/h, & Lopressor 200mg/per day (for chest pain).
Current medical Diagnoses - Angina, Hypertension
Allergies - NKA/NKDA
Childhood Illnesses – Influenza and Chicken Pox
Previous medical conditions/hospitalizations/surgeries –
Accidents/ injuries - Fell down 2 months ago, did not seek medical attention. Bruises on left arm (healed). No injuries to head.
Travel - Italy 3 months ago.
Immune – tetanus, Rubella, Mumps, Polio, Hepatitis B, Varicella, Flu, Pneumonia
Dates of last: Physical, vision and hearing Examination 4/2014 Dental 2/2014 Male: prostate and testicular exam 4/2014
Family History
Mother- 80 Deceased ; Hypertension, Type II diabetes
Father- 76 Deceased MI; Hypertension
Didn’t know maternal grandparents
Fraternal Grandparents * Grandmother – 65 deceased from natural causes * Grandfather – 51 deceased MI
Father’s brother – 51 HTN, CAD
Spouse, 53. Hypertension
Son 25, no known.
Personal and Psychosocial
Lives with wife, and a block away from Son. Very close with known family members.
3 meals a day, including soda for lunch, and beer and red wine for dinner. Fruits and vegetables for dinner. Does eat some fast food and other foods high in saturated fat
15 minute walk 3 times a week.
Sleep 6 to 8 hours a night; wake up at least once every night for bathroom.
Maintain oral hygiene, brush teeth twice a day, & flossing at night.
Watch school sport’s game, read books, cook in the house.
Functional abilities: pt says he’s able to perform all ADLs and IADL
Tobacco: 1 pack/day for 35years = 35 pack years ([20/20]x35; Alcohol: Drinks regularly either 2-3 beers or glasses of wine/ night Recreational drugs: Pt says none currently but has smoked weed and used cocaine in the past.
Personal Habits
Self-exam: looks in the mirror when getting out of the shower
Physical: once a year Dental: every 12-18 months
Review of body systems
General Health: Tightness around chest area, and left shoulder. As well as SOB
S,H,N: Pt denies any changes of skin pigment, hair, and nails. Pt had good capillary refill and skin turgor.
Hair and Neck: Pt c/o light headedness and dizziness upon position changes and sometimes upon physical assertion. Sometimes has a ‘stiff neck’ upon waking up occurs 1-2 times/month which he says taking an OTC analgesic relieves.
Eyes and Ears: Pt says he has 20/20 vision and his hearing is good but has experienced ringing in the ears but very rarely and the issue resolves itself.
Nose, mouth, throat, sinuses: Pt expressed sometimes the chest pain radiates to jaw.
Beast and Regional Lymphatics: pt said he has had no problems with his breast or lymph systems
Respiratory: Pt said he’s had no DX of resp illness. Pt does experience SOB during instances of physical exertion (climbing stairs [more than one flight], walking extended periods [longer than 7-10 minutes] and lifting and carrying heavy loads) SOB is further exacerbated when the temperature is below 40 degrees and above 80 degrees. Has been an issue since before his angina DX. Does not affect his sleep or express instances of orthopnea. Said he doesn’t have a cough
Cardiovascular: Pt said he has experienced nocturia almost every night with no relieving factors. Pt his been DX with angina and hypertension, pt says he’s current on all his medications taking them as prescribed, but still has exacerbations of angina. During exacerbations of angina pt said he is normally doing one of the physical activities previously stated or work around the house outside until the onset of symptoms that forces him to stop due to pain. The pain will start in his chest as tightness/pressure then sometimes radiate to his jaw or left shoulder and arm, with a duration of 3-7minutes and is normally relieved upon rest. Does not know exact results from blood work but says it was done within the past two years and the doctor told him that all his values were within normal range.
Peripheral Vascular: Pt says he hasn’t experienced any tingling in his feet or hands besides the normal ‘my foot has been asleep before’. Pt has normal capillary refill and skin turgor.
Abdominal/Gastrointestinal: pt says he hasn’t had food/digestion problems.
Genito-urinary/sexual HX: Pt experiences nocturia once a night around 2-4am. This has been going on ‘as long as he could remember’ never has he had an ‘accident’ where he didn’t make it to the bathroom in time. When going to bathroom he is able to full void. He says he hasn’t experienced any sexual dysfunction.
Musculoskeletal: No HX of any disease of the muscles or bones. Says he isn’t as strong as he once was but besides the above noted limitations to physical activity he is able to do as he pleases.
Neurological: No history or presenting symptoms of any neurological issues.
Hematologic: Pt said he has no known blood disorders or issues.
Endocrine: No known issues but is aware of family HX of DM from his mother and says he eats fairly healthy but does cheat with junk food 1-2x a week.