Case study: 64 year old Hispanic male with PMH of hypertension and dyslipidemia
Case study: 64 year old Hispanic male with PMH of hypertension and dyslipidemia
Informant: Patient, who is AOX3 and old chart.
Chief Complaint: This is 64 year old Hispanic male with PMH of hypertension and dyslipidemia present to the clinic with chest discomfort. Patient stated that chest discomfort is in the middle of his chest and it feels like a burning sensation along with tingling.
History of Present Illness: Mr. JG. is a 64-year old male with a history of HTN and dyslipidemia present to the clinic with chest discomfort for past two month. Patient stated that chest discomfort is in the middle of his chest and it feels like a burning sensation along with tingling. Patient rated his pain 5 out of 10. Patient also stated that mostly happen when I am doing activity like climbing stairs however sometime it does happen when I am just watching TV. Patient denies any episodes of felling dizzy or passing out. Patient denied radiation of the pain to neck or jaw. He took Advil and it is not doing anything. Patient is non-compliance with his cholesterol medication.
Current Regimen: Lisinopril 5 mg daily
Hydrochlorothiazide 25 mg daily
Past Health General: Hernia repain 2002, Last mammogram 2004, colonoscopy 1997, relatively good health otherwise.
ROS: General: has slowly gain weight over last ten years, denies weakness, , fevers, memory changes, nervousness, anxiety,depression, suicide.
Skin: no rash, lumps, sores, itching, dryness, color change, change in hair/nails, bruising or bleeding, excessive sweating, heat or cold intolerance.
Head: Denies headache, head injury, dizziness.
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred vision, or blindness.
Ears: no hearing change, tinnitus, infection, discharge.
Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.
Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago.
Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.
Neuro: No syncope, seizures, weakness, paralysis, numbness, tremors, or involuntary movements.
Pulmonary: Dyspnea with activity, negative hemoptysis, wheezing, pleuritic pain
Neuro: No headache dizziness, focal numbness/weakness, nausea, vomiting.
Cardiac : See HPI.
MS: no muscle, joint pain, or joint stiffness, positive for chest pain
GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain,
belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food
intolerance, indigestion, nausea, vomiting, early fullness, odynophagia.
GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria,
nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids.
Social History: Patient has never smoked. She drinks alcohol rarely, does not use recreational drugs and is monogamous in a married relationship for many years. She has two grown children and works as a secretary. She does not exercise on a regular basis. Dietary history was not detailed but she did admit to eating “quite a bit of fast food.
