Patient Demographic Information: GH Date/Writer: 1/18/12; 9:00 P.M.

____, MS 2 Source and Reliability of Information: patient; accurate historian CC: chest pain HPI: GH is a 70 year old male, with a history of coronary artery disease, who presents to the emergency room with a chief complaint of mild chest pain for the past 12 hours. GH notes that he has had these uncomfortable chest pains on and off for two years, but they would always get better after a few minutes. GH notes that his chest pain started today during his exercise session at 9:30 am. When the chest pain did not subside, he took two aspirin tablets (162 mg) at which time the pain went away but then came back. A few hours later at 12:45 pm he took a nitroglycerin pill which temporarily alleviated the pain. He came to the emergency room when the chest pain started again an hour later. GH describes the chest pain as a dull nagging ache with light pressure and rates it a 1 out of 10 on a pain scale. He notes that exercise provokes the pain and aspirin and the nitroglycerin make the pain better (similar to previous episodes). He denies radiation of the pain to anywhere else on his body. He denies SOB, N/V, and arm numbness/ tingling. GH describes a similar episode of unrelenting chest pain one year ago when 6 coronary blockages were found and stented, and he expresses a concern that another blockage has formed. He also notes recently beginning an exercise regime after a 4 month hiatus, and dealing with the stress of placing his mother in a nursing home. He is concerned that the added stress might cause an MI. Past Medical History: Current/Past Illnesses: asthma (since childhood), hypertension (since age 40), arthritis of lower back Hospitalizations: Six stent placements in RCA and LAD (2011) Surgeries: Two rotator cuff repairs (2001, 2006) Left knee replacement (2007) Left elbow repair (1973) Two hernia operations (1966, 1975) Medications: advair (dosage unknown), amox (2000 mg), doxazosin (1 mg), HCTZ (50 mg), KLOR-KAN (10 meq), losartan (100 mg), aspirin (355 mg), albuterol (PRN), allopurinol (300 mg), felodipine (70 mg), diclofenac (75 mg), simvastatin (dosage unknown), effient (dosage unknown) Allergies: patient claims allergy to effient with skin itch and rash Family History: Mother 89 years old with Type II diabetes, COPD and history of heart disease and MI. Father current status or medical history unknown. Two brothers passed at age 61 from pancreatitis and 64 from pancreatic cancer. One

surviving brother age 67 with Type II diabetes and hypertension. One sister 66 years old with no known health problems. One biological son age 40 with bipolar disorder. Patient claims diabetes, hypertension, heart disease, and cancer run in the extended family. Social History: GH is a retired machinist and truck driver. He is married and currently lives with his wife. He has no safety or health concerns about his living arrangement. GH claims his chest pain and putting his mother in a nursing home to be significant life stressors but notes that he has a good support network when needed. GH notes previous use of tobacco of 1 pack a day for 30 years prior to 1986. He denies use of recreational drugs. He denies alcohol use. Sexual history and nutritional history not taken. Review of Systems: General: positive for fatigue; denies fever, chills, change in appetite/weight, insomnia Skin: denies rashes, lesions, changes in moles HEENT: denies dizziness, syncope, vertigo, head injury, vision change, blindness, ocular trauma, eye redness/dryness/discharge, hearing change, epistaxis, rhinorrhea, dysphagia, mouth sores, tooth pain Neck: denies masses, stiffness Cardiac: see HPI; denies palpitations, dyspnea on exertion, nocturnal dyspnea, change in pillow count, lower extremity edema Pulmonary: denies SOB with rest/activity, cough, mucus, wheezing, pleuritic CP GI: denies nausea, vomiting, heartburn, abdominal pain, bloating, change in bowel habits, diarrhea, constipation, rectal bleeding, black or tarry stools, jaundice, increase in abdominal girth Musculoskeletal: denies muscle aches, joint pain, stiffness, swelling, limited movement, trauma Neurologic: denies numbness, weakness, tingling, dizziness, difficulty with balance/walking, headaches, vision changes, memory problems Heme/immunology: denies easy bruising, easy bleeding, recent travel Psychiatric: denies poor concentration, depression, suicidal/homicidal ideation Physical Exam: General Appearance: GH is an overweight male, who appears to be sitting comfortably in no acute distress. Vital Signs: BP: 143/89, HR: 64, RR: 17, temperature: 98.5, pulse ox: 96% on room air Skin: color pink, no evidence of central or peripheral cyanosis, multiple well-healed surgical scars (L knee, L elbow, bilateral inguinal regions), no rashes HEENT: Normocephalic, atraumatic, conjunctiva clear, PERRL, extraocular movements intact; full visual fields to confrontation; fundi visualized with no hemorrhages or exudates; disc margins sharp, EAC clear bilaterally; tympanic membranes translucent; gross hearing intact; normal Rinne and Weber, nasal septum

midline, normal pink mucosa, no sinus tenderness, oropharynx moist mucous membranes, good dentition, no tonsillar erythema or exudates, symmetric elevation of soft palate, tongue midline Neck: supple, full ROM, no lymphadenopathy, no thyromegaly Heart: PMI well-localized at 5th intercostal space; no heaves, lifts, or thrills; normal intensity S1 and S2; II/VI systolic, crescendo-decrescendo murmur, loudest at the left upper sternal border, no clicks, or rubs; no JVD; hepatojugular reflux not tested; no carotid bruits; capillary reflex 2 sec; DP and radial pulses symmetric bilaterally Chest/Lungs: thorax symmetrical, no use of accessory muscles, no tenderness on palpation, normal to percussion, symmetric tactile fremitus, clear to auscultation-no rales, rhonchi, wheezes, or rubs Abdomen: protuberant, normoactive bowel sounds, normal resonance to percussion, no shifting dullness, soft, non-tender, non-distended, no pulsatile mass, no hepatosplenomegally appreciated Rectal: normal rectal tone. Brown stool. Hemoccult negative. Musculoskeletal: no LE tenderness on palpation, no palpable cords, no swelling, negative Homans sign Neurological: AO x 3, CN II XII symmetric and intact, strength 5/5 in all extremities, sensation grossly intact to light touch EKG: rate 78, rhythm regular, axis normal, QRS narrow, QT interval 420 ms, no evidence of Q waves, no ST elevations, depressions, or T wave inversions Labs:
141 4 110 24 43 115 2.16

Troponin I: <0.15 ng/mL Formulation: In summary, GH is a 70 year old male with a history of coronary artery disease, who presents with mild chest pain for the past 12 hours. As the pain is similar to his episode last year, it is likely that he has stable angina as a result of another coronary artery block. He might also be in the early stages of a mild MI, which his labs and EKG may not have reflected yet. Of interest is his creatinine which indicates a decreased renal function, possibly due to the NSAIDs he had been taking for his arthritis. The next step would be to admit him into the hospital and do a heart catheterization to visualize any possible blockages. Reflection: Patient GH proved to be a challenge for me in a different way. As I have become comfortable with practicing the physical exam and talking to patients, I have discovered a new challenge: conducting the interview in a timely manner. GH had much to say for every single question that I asked him. Often times his wife also had many things to add. Patient GHs stories were so interesting that I found myself engrossed in them and I

struggled to keep the interview and physical exam moving. However, I was also able to build a great relationship with the patient and get a lot more information from him. I think this is a balance I am going to have to work on in the future. Also, I was present when the cardiologist broached the subject of advance directives with patient GH. It was an interesting experience as I have never witnessed such a conversation in an actual clinical situation. The conversation was a lot more casual than I had expected. The cardiologist simply asked GH how he would like to live his life if anything were to happen during future procedures. While the tone was casual, I noticed that I was a bit uncomfortable, especially since the conversation was occurring in light of chest pain and a possible MI. However, the patient took the questions and conversation well and responded accordingly. I believe that this conversation proved to be an excellent example of how to handle these difficult conversations in a professional manner.