Cardiology
TAPE 8A, Report 8
HISTORY AND PHYSICAL EXAMINATION
CHIEF COMPLAINT
Precordial-type squeezing chest pain radiating to left shoulder and left arm, unrelieved for approximately 24 hours’ duration.
PRESENT ILLNESS
This 68-year-old Caucasian male with a history of hypertension and congestive heart failure was apparently in good health, although he had failed to follow up on his office appointments and ran out of refills on probably his Lasix 1 week ago. The patient shortly thereafter had some slight precordial chest pain which resolved. The precordial chest pain returned again. Patient obtained good relief with nitroglycerin sublingual. Patient has also been on Calan and Micro-K, which he has continued to take. He has had no chills or fever, no nausea, emesis, or diarrhea, no unusual color change. He did complain of being somewhat diaphoretic and dizzy with the chest pain.
FAMILY HISTORY
No familial diseases known.
PERSONAL HISTORY
Patient is known to imbibe alcohol and perhaps to excess on occasion. He does not smoke.
PAST MEDICAL HISTORY
Patient has had an appendectomy, a tonsillectomy, and an umbilical herniorrhaphy.
SYSTEM REVIEW
System review is essentially negative.
PHYSICAL EXAMINATION
VITAL SIGNS: Blood pressure 160/110, respirations 20, pulse 87, temperature 98.
GENERAL APPEARANCE: A slightly obese, well-developed,
68-year-old Caucasian male.
68-year-old Caucasian male.
HEENT: Head symmetrical. Pupils equal, react to light and accommodation. No scleral icterus. Ears, nose, and throat clear. Mouth moist.
NECK: Supple, no masses. Normal anterior carotid pulsations bilaterally.
CHEST: Clear to P&A.
CARDIOVASCULAR: Distant heart tones. No murmurs. Good peripheral pulses, including dorsalis pedis.
ABDOMEN: Protuberant. No masses. Active bowel sounds.
GENITALIA: Normal male.
RECTAL: Deferred.
EXTREMITIES: Negative x4. No ankle edema.
NEUROLOGICAL: Physiologic.
IMPRESSION
1. Probable angina pectoris.
2. Rule out myocardial infarction.
3. Congestive heart failure, compensated.
4. Hypertension.
5. Arteriosclerotic heart disease.
FOOTNOTE
Line 18 (Page 1). The slang term nitro was translated as nitroglycerin.
Line 39 (Page 1). The subheading Vital Signs was added.
Line 11 (Page 2). MI was expanded in the Impression for clarity.
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