Date of Encounter: 9/23/11 College of Medicine History and Physical Examination CHIEF COMPLAINT: chest pain HISTORY OF PRESENT

ILLNESS (HPI): 1. Mr. John Anderson is an 89-year-old male with a 6-hour history of chest pain. 2. He woke up suddenly last night about 2:30 am with pain he rates a 7 out of 10. He notes, it feels like a rhinoceros [is] sitting on my chest. The pain is mostly in his left chest and left shoulder, moving a little into his right shoulder. The pain lessens when he sits up and is worse on exertion. It is constant. In the past 2 weeks, he has experienced short (3-minute) bouts of similar pain (7 out of 10) which are also aggravated by exertion and get better when he sits up. These occur at night: he wakes up suddenly, hot and stressed, sweating and with a racing heart. He observes that this might be due to the hot weather, but admits his A/C is working fine. He reports feeling weak, fatigued, and unrefreshed because this causes him to lose sleep. Before two weeks ago, he got up at night to urinate occasionally, but sees a urologist and takes no medication for this. Before two weeks ago, he slept on one pillow; for the past two weeks, he has slept on 3 or 4 if he wakes up at night. Taking two baby aspirin has resolved the problem until last night. Mr. Anderson reports shortness of breath on exertion, such as after walking 2 miles or walking up 2 flights of stairs. He also relates feeling faint when he stands up too fast, and has fainted 5 times, the last being 3 years ago. Today he reports feeling dizzy and explains that his head hurts. 20 years ago (age 69) Mr. Anderson suffered a myocardial infarction and was hospitalized for 4 days. Before this, he had acquired a 25 pack-year smoking history (half a pack a day over fifty years) and consumed alcohol. After his MI, he stopped smoking and drinking; he notes it was easy to quit drinking. He also lost 57 lb. Today, he weighs 173 lb. and maintains a healthy diet. His exercise regimen includes walks and cutting the grass. Mr. Andersons blood pressure is slightly elevated. His physician observed a heart murmur 30 years ago which is still observed today. He takes one 81mg aspirin PO daily and a multivitamin. His last stress test 10 years ago was good. His father had coronary artery disease and died at age 75 of a heart attack. His brother has diabetes; Mr. Anderson doesnt know what type. 3. Mr. Anderson denies lower leg pain while walking, edema, change in weight, appetite, fever/chills, heat/cold intolerance, excessive thirst, and hunger or urination. He denies cough, sputum production, hemoptysis, wheezing/asthma, TB or exposure to TB, and recurrent respiratory infections. Mr. Anderson also denies anorexia, weight loss, dysphagia, nausea/vomiting, hematemesis, abdominal pain, heartburn, excess gas/belching, constipation, diarrhea, change in bowel habits, melena, hematochezia, food intolerance, antacid/laxative use, and jaundice. PAST MEDICAL HISTORY: Childhood: UCHD Adult: List significant/chronic adult medical problems

Medical illnesses: N/A Hospitalizations: 1. 1991 for MI, 4 days 2. 2003, R knee replaced, 1 day and 3 months rehab Psychiatric: none Accidents/Injuries: none Transfusions/Toxic Exposures: none PAST SURGICAL HISTORY: 1. R knee replacement 2003 CURRENT MEDICATIONS: 1. Multivtiamin, po 2. 81 mg aspirin, 2 daily, po ALLERGIES: sulfa drugs FAMILY HISTORY: Father Grandfather Grandmother Mother Grandfather Grandmother Brothers Sisters Children Current age (or age at death) (75) Patient does not recall Patient does not recall (75) Patient does not recall Patient does not recall 87 N/A daughter, 55 in good health Current health/illnesses (or cause of death) MI, CAD colorectal cancer diabetes

Denies family history of stroke, kidney disease, and sickle cell or other anemia. Personal/Social History: Married, lives at home with wife Retired banker 25 pack-year history, quit in 1991 Stopped use of all alcohol without difficulty in 1991 No recreational drug use 1-2 cups of caffeine daily Good diet, moderate exercise (walks and mows lawn) Sleep only interrupted by nocturne before two weeks ago; now wakes up with difficulty breathing HEALTH CARE MAINTENANCE: Immunizations: Mr. Anderson is up-to-date on all immunizations except flu, pneumonia, and shingles. Health Care Screening: Mr. Andersons last colonoscopy 1 year ago was normal. See HPI for stress test. REVIEW OF SYMPTOMS (ROS): General/Endocrine: see HPI

Skin: Mr. Anderson reports a general red rash all over, but denies pruritus, dryness, hives/wheals, new growths, changes in existing nevi, and changes in skin, hair or nails. Head: Mr. Anderson denies head trauma and scalp lesions. Eyes: Mr. Anderson admits poor vision since his last eye exam was 50 years ago. He denies halos/flashes, blurring, diplopia, scotoma, redness, pain, photophobia, lacrimation, dryness, and inflammation. Ears: Mr. Anderson has some hearing loss but does not wear a hearing aid. He denies tinnitus, vertigo, earache/pain, and discharge Nose: Mr. Anderson has some congestion from cutting the grass. He denies rhinorrhea, sinus pressure, pain, and nose bleeds. Mouth/Throat: Mr. Anderson wears dentures. He denies any problems with these and also denies ulcers, salivation, tongue, soreness, abnormal taste, teeth/dentures, gum problems, sore throat, hoarseness, and difficulty with speech. Neck: Mr. Anderson denies stiffness, masses, thyroid problems, and swollen glands. Breasts: N/A Cardiovascular: see HPI Respiratory: see HPI Gastrointestinal: see HPI Genitourinary: Urinary: Mr. Anderson sees a urologist because he wakes up at hight to urinate. He denies dysuria, urgency, frequency, incontinence, difficulty starting stream, hesitancy, dribbling, decreased strength of stream, hematuria, renal colic/stone. Female Gyn: N/A Male: Mr. Anderson denies penile discharge/sores, testicular pain/mass, hernias, history of venereal disease, sexual dysfunction, and erectile difficulties. Heme: Mr. Anderson denies abnormal bleeding/bruising, anemia, and lymphadenopathy. Musculoskeletal: Mr. Anderson admits some joint pain in his R knee replacement which slightly restricts how far he can bend it, but it does not bother him. He denies swelling, redness, warmth, stiffness, locking, laxity and deformity. He also denies bone pain, myalgia, and back pain. Neuro: See HPI; also, Mr. Anderson admits occasional minor memory loss. He denies paralysis/paresis, seizures, tremors, ataxia, paresthesia, and involuntary movements. Psychiatric: Mr. Anderson denies feeling nervous, jittery, worried, sad, blue, down, etc; he denies crying, inability to concentrate, insomnia, difficulty concentrating, change in mentation or behavior, and hospitalization for mental illness.