Anish Shah Clinical Skills Maxwell, Sewell, Holland-Barkis September 19, 2012 History Chief Complaint 48 year old,

, Caucasian male complaining of chest pain and shortness of breath. History of Present Illness Dr. Maxwell is a 48 year old Caucasian male who complains of chest pain and shortness of breath. The problem started 6 months ago and has been progressively becoming more severe, particularly in the last few weeks. The location of the pain is directly in the middle of his choice, approximately the 4th rib level of the sternum and a tad to the right (according to his hand placement when asked to locate the pain). This pain also radiates into his left shoulder at times. He describes the pain as a pressure on his chest that comes and goes, rating the pain intensity as a 5 out of 10. The pain is relieved when he stops activity. His main example is when going on a routine walk, he can no longer climb a hill without stopping ever few minutes. These symptoms have never been presented prior to now. He specifically denies chest pain and shortness of breath prior to this illness. He does not have diabetes. He admits to taking medication for blood pressure (hypertension) and for high cholesterol, as well as aspirin for heart health. His entire family has heart disease, hypertension, and high cholesterol. Past Medical History Childhood illnesses - ear infections - mumps - chicken pox Adult Illnesses - hypertension, last ten years or more - igh cholesterol, last ten years or more Past Surgical History Hernia repair, adult Appendectomy, adult Medications Attenalol, 25 mg a day by mouth for blood pressure Lysinopril, 10 mg per day by mouth for blood pressure Aspirin, 1 baby-sized by mouth per day

Anish Shah Clinical Skills Maxwell, Sewell, Holland-Barkis September 19, 2012 Zocor, 20 mg per day by mouth for cholesterol Allergies Allergic to penicillin, causes a rash Family History All family members had heart disease, hypertension, and high cholesterol. Grandmother had diabetes. Dad died at 57 Mom died at 55 Grandfathers died in 70s Grandmothers died in 70s Only child Social History Dr. Maxwell works as a computer programmer and lives a not too stressful life, and also works from home. He his married with two children, is a smoker (1-pack per day for 30 years) since age 18. Is a light drinker, just a beer every now and then. Is a sexually active male with just his partner and is doing just fine. He exercises daily by walking 45 minutes to an hour, although has problems going up hill. Health Care Maintenance Immunizations may be current, is unsure. Mild exercise, 1 hour daily Review of Systems Endocrine no weight changes, fatigue, or fever, no night sweats Head has headaches, has alopecia Eyes no vision problems, glaucoma, or cataracts Ears no hearing problems Nose no noise problems Mouth has healthy teeth and gums Neck no neck problems Respiratory has shortness of breath, but none prior to now, no asthma or other respiratory problems Cardiovascular EKG taken 5 years ago, no stress test Gastrointestinal - no stomach problems, but occasional heart burn, regular bowel movements Genitourinary no genitalia problems, no liver or urinary problems

Anish Shah Clinical Skills Maxwell, Sewell, Holland-Barkis September 19, 2012 Musculoskeletal broken thumb at age 16 Skin no skin changes, no lumps or bumps Heme no blood problems Psychiatric has no mood problems Neurological no seizures or faintings Assessment 1. 2. 3. 4. 5. 6. 7. Plans 1. 2. 3. 4. 5. 6. 7. Admit as outpatient to check condition of heart through radiology Consult a real doctor Consult an actual cardiologist Stop smoking Continue current hypertension and cholesterol medication Plan to strengthen exercise routine after taking care of present illness Ask for followup in 6 weeks Chest pain with shortness of breath, Dx of CHF Class II Consistent smoker General obesity Hypertension, but medicated High cholesterol, but medicated Strong family history of CVD Needs to check his vaccinations

Anish Shah, MD-not