IM – Chest Pain | CLINIBORG

new patient existing patient history provided by patient history provided by family member SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA

RECENT HISTORY:
non-contributory visit to ER/UC hospitalization/surgery/procedure new medications antibiotic use diagnostic study

CC:

Similar Sx Before:
yes no

Location:
larynx suprasternal notch precordial epigastric under left breast

Onset:
days ago hours ago at rest with activity upon emotion upset drinking coffee using stimulants unsure

Time Course:
still present better worse resolved lasted seconds lasted minutes lasted hours unsure

Quality:
pressure tightness dull burning sharp stabbing numbing indigestion unsure

Radiation:
arm back neck jaw none unsure

Worse with:
change in position deep breathing turning exertion unsure

Better with:
change in position sitting up rest antacids unsure

ASSOCIATED SYMPTOMS:
CP chest pain with deep breathing feeling of doom SOB cough orthostasis orthopnea nocturia PND weight loss weight gain hypoglycemia leg swelling syncope near-syncope palpitations sweating dizziness nausea hand/face numbness/tingling none reported unsure

MEDICATIONS:
allergies reviewed
nitrates b-blocker insulin NSAID BCP ASA Plavix anticoagulants taking as prescribed not taking as prescribed reports no side effects reports side effects effective partially effective not effective demonstrates knowledge of medications/reasons/dosages unable to name medications/reasons/dosages medication list/labels/containers available for review medication list/labels/containers not available for review

AMBULATORY MONITORING:
insulin/BS log available for review insulin/BS log not available for review BP record available for review BP record unavailable for review reports checking BP at home reports not checking BP at home reports checking BS at home reports not checking BS at home

PMH/Comorbidities:
hypertension LVH, CHF CAD,MI CVA,TIA PAD ED aneurysm atrial fibrillation PE,DVT COPD BMI≥30 dyslipidemia diabetes retinopathy microalbuminuria GFR < 60 snoring,sleep apnea cancer recent surgery/hospitalization/procedure GERD anxiety stress

PSH/CARDIAC PROCEDURES:
none reported angio/stent CABG pacemaker carotid endarterectomy

CV STUDIES:
none reported stress test ECHO vascular U/S calcium score tilt table

PERTINENT SH:
non-contributory tobacco cocaine meth use

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI

Constitutional:
fever chills body aches malaise fatigue night sweats hot flashes unintentional wt loss wt gain

Head/face:
headache trauma facial pain facial swelling facial drooping facial numbness

Eyes:
decrease in vision scotoma floaters blurriness photophobia halos dryness redness/irritation discharge lid swelling periorbital swelling trauma pain with EOM

Ears:
pain pressure discharge bleeding wax hearing loss ringing

Nose:
discharge PND congestion sinus pressure snoring bleeding trauma

Mouth:
sores dryness tongue pain/swelling toothache infection/swelling jaw pain/clicking changes in taste

Throat:
sore throat odynophagia dysphagia hoarseness globus

Neck:
pain stiffness swelling swollen glands

CV:
chest pain/pressure SOB palpitations lightheadedness fainting exertional dyspnea orthopnea ankle swelling ankle discoloration varicose veins leg cramps

Chest/Respiratory:
cough phlegm wheezing pain w/ breathing rib pain breast swelling/lump

GI:
poor appetite nausea vomiting abdominal pain constipation diarrhea

GU:
dysuria burning frequency urgency hematuria hesitancy retention dyscharge bleeding

MSK:
myalgias neck pain back pain shoulder pain hip pain knee pain chronic pain/meds joint pain/deformity localized muscle/soft tissue pain/swelling

Neuro:
dizziness vertigo poor balance abnormality of walk focal weakness blackouts speech difficulty tremor seizures urinary/bowel changes tingling/numbness

Psych:
irritability confusion withdrawal depression apathy anxiety mood swings memory loss insomnia

Endo:
cold intolerance skin dryness hair loss polyuria

Lymph/Hema:
gland swelling bruising anticoagulation DVT/clotting anemia

Immune:
atopy food allergies autoimmune dz h/o cancer

Derm:
dryness pruritus rash hives redness swelling wounds

Ambulation/DME:
no ambulation aids/DME ambulation requires walker ambulation requires cane ambulation requires wheelchair wearing cervical collar wearing lumbar support wearing extremity brace

Appearance:
well-appearing no signs of discomfort visible while sitting in chair no signs of discomfort visible while ambulating & getting on/off exam table good hygiene normal built heavy built lean well-nourished emaciated frail ill-appearing tired-looking short of breath diaphoretic disheveled bizarre clothes body odor drowsy appears impaired slumped

Skin:
grossly intact, no rashes no bruises normal turgor tattoos body piercings poor turgor dry sweaty

Head/Face:
normocephalic, atraumatic normal hair distribution symmetrical face CN grossly intact plethoric face alopecia facial droop

Eyes:
clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus visual acuity grossly intact cornea(s) clear glasses contacts conjunctival injection epiphora conjunctival exudate allergic shiners dysconjugate gaze

Ears:
symmetrical & intact auricles bilaterally hearing to conversation intact clear canals without erythema or discharge TMs normal in appearance

Nose:
nares patent bilaterally septum midline no facial tenderness mucosa pink & moist swollen & boggy mucosa mucosal congestion clear discharge yellow discharge crusty discharge rhinophyma

Mouth:
tongue normal in appearance w/o lesions and with good symmetrical movements moist oral mucosa without lesions upper denture lower denture poor dentition oral ulcers gum swelling tooth decay

Throat:
normal voice patent pharynx w/o swelling or exudates uvula midline clear pharynx w/o exudates hoarseness vesicles on soft palate petechiae on soft palate pharyngeal erythema w/o exudates

Neck:
symmetric with free painless ROM and no masses supple no LAD no bruit or JVD anterior LAD posterior LAD thyroid enlargement nuchal tenderness

Chest/Lungs:
normal work of breathing, symmetrical chest expansion, no stridor clear and equal breath sounds bilaterally chest wall atraumatic and non-tender no axillary or supraclavicular LAD SOB decreased bilaterally wheezing crackles

CV:
regular rhythm no murmurs no ankle edema pedal skin warm with good & equal pulses tachycardia irregular heart rhythm systolic murmur calf tenderness ankle edema varicosities stasis discoloration

Abdomen:
not examined normal visual inspection, no distension normal active bowel sounds soft non-tender no abdominal bruit/pulsations protruding surgical scar umbilical hernia diffuse tenderness over entire abdomen w/o RRG hypoactive bowel sounds hyperactive bowel sounds direct non-rebound tenderness colostomy in situ

GU:
not examined no suprapubic tenderness no CVAT bilaterally Foley in situ normal external genitalia no inguinal LAD testicular tenderness urethral discharge verrucous papules vesicles crusted lesions

MSK:
no gross deformities, moves all extremities with good ROM for age full weight-bearing normal curvature & ROM in C- & L-spine for patient’s age non-tender C-spine with good ROM non-tender L-spine with good ROM strength, tone, & bulk symmetrical & grossly intact kyphosis paraspinal muscle spasm C-spine tenderness & DROM neck pain with active motion paracervical muscle spasm old surgical scar(s) in C-spine trapezius tenderness L-spine tenderness reduced painful ROM in lumbar region paraspinal muscle spasm trigger points in L-spine old surgical scar(s) in L-spine heel-walk & toe-walk without difficulty negative seated SLR positive seated SLR

Neuro:
normal concentration and attention memory grossly intact balance & coordination grossly intact ambulates w/o limp or alteration in gait extremities strong w/o atrophy no gross motor deficits sensation symmetrical & grossly intact no involuntary movements or tremor antalgic gait wide gait shuffling gait diffuse numbness w/o dermatomal pattern dystonia tardive dyskinesia tics

Speech/Vocalization:
normal for age clear & coherent slurred mumbling to self monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured groaning sighing crying perseveration flight of ideas repetitive questions self-depreciating statements repetitive statements of impending doom repetitive non-health related/financial concerns personal safety concerns suicidal ideation/threats insisting on particular medication, test, referral, or accommodation raising voice defensive argumentative cursing, swearing previous providers/staff criticisms verbal threats sexual remarks racist remarks

Behavior/Psychomotor Activity:
calm, pleasant, respectful cooperative with history & exam guarded anxious irritable frustrated labile agitated hostile forceful pacing fidgeting picking skin twirling hair cracking knuckles grimacing, furrowing eyebrows tightening jaw breathing hard intense staring threatening gestures fist-clenching withdrawn flat affect bradykinetic indifferent appears to be responding to internal psychotic process

OFFICE DIAGNOSTICS:
EKG RBS normal non-specific changes no acute findings discussed with patient/SO official report to follow

A/P:

RX:
none OTC electronic paper given to MA to be transmitted to pharmacy

LABS:
none CBC CMP TSH A1C Lipids PSA FOBT/FIT UA HIV, RPR, HCV, GC, CT UDS

IMAGING:
none X-ray US MRI

OUTSIDE REFERRALS:
none

STAFF INSTRUCTIONS:
none dsg change/wound care as instructed obtain hospital/ER discharge report obtain specialty report obtain imaging report obtain laboratory report remind patient to always bring all medication containers to visit

FORMS:
none excuse clearance restrictions

REVIEWED/DISCUSSED:
MA notes med list medication containers PMP previous visits laboratory/diagnostic studies specialty reports hospital discharge

INSTRUCTED ON:
exam findings, POC, risks of/benefits of/alternatives to proposed POC, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services
alcohol cessation smoking cessation weight reduction/exercise salt restriction carbs restriction appropriate follow up medication compliance bringing all medications/labels to all visits home BP checks home BS checks daily weights controlling chronic conditions age-appropriate screening and immunization

PLAN OF CARE:
patient/family verbalized understanding of & agreement with POC patient/family did not agree with my POC – will seek second opinion/further care elsewhere

PREVENTIVE:
UTD deferred colonoscopy DEXA LDCT PAP mammogram PSA DRE referred to local pharmacy to verify vaccination status and administer vaccines, if indicated

DISCHARGE CONDITION/SAFETY:
improved stable unchanged no safety concerns at this time safety concerns d/t depressed agitated mood safety concerns d/t impulsiveness safety concerns d/t hostile temper safety concerns d/t past attempts safety concerns d/t current suicidal verbalization

FOLLOW UP:
as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx
RTC 24 hours RTC 2-3 days RTC 1 week RTC 4 weeks medication review f/u acute episode f/u labs f/u imaging f/u referral

DISPOSITION:
home referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left clinic before being discharged asked to leave clinic

BARRIERS TO CARE:
none apparent at this time incomplete history d/t poor effort incomplete history d/t cognitive changes incomplete history d/t distress/affect incomplete history d/t language barrier vague shifting complaints history not supported by objective findings supporting documentation unavailable incomplete exam d/t safety concerns poor cooperation with exam multiple comorbidities polypharmacy poor compliance with POC intolerance of/therapeutic failure on multiple meds preoccupation with illness catastrophization overgeneralization unrealistic beliefs negativism pessimism blaming others lack of motivation negative attitude to diagnostic impression & proposed tx lack of interest in nonpharmacologic therapies psychiatric comorbidity h/o alcohol/substance abuse victim of abuse social/cultural barriers altered mental status affect hostile/disruptive behavior

IM – Chest Pain

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