NURS 6512 DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM Name: Brian Foster Age: 58 years Sex: Male Race: Caucasian Chief Complaint (CC): “I have been having some troubling chest pain in my chest now and then for the past month.”

 NURS 6512 DIGITAL CLINICAL EXPERIENCE: ASSESSING THE HEART, LUNGS, AND PERIPHERAL VASCULAR SYSTEM

Name: Brian Foster

Age: 58 years

Sex: Male

Race: Caucasian

Chief Complaint (CC): “I have been having some troubling chest pain in my chest now and then for the past month.”

History of Present Illness (HPI): Brian Foster is a 58-year-old Caucasian male presenting with troubling chest pain since the last month. The pain is situated in the middle of his chest. Currently, the pain is at zero although he rates the pain at 5/0 during the previous episodes. It is usually a tight uncomfortable feeling that is neither burning nor crushing. He had 3 episodes in the past month. The initial episode commenced with physical activity, while he was doing his yard work whilst the second episode commenced when he was taking stairs at work. The most recent episode was three days ago. These episodes lasted only for a few minutes and they all felt the same. The pain does not radiate to the neck, shoulder, back, or even to the arm and is not associated with food intake. It is aggravated by physical activity and relieved by laying down with a brief rest. Has not taken any medications for the chest pain.

Medications: Metoprolol 100 mg PO once daily, atorvastatin 20 mg PO once daily, and omega 3 fish oil 1200mg PO once daily. He occasionally takes over-the-counter medications particularly Tylenol or Motrin when having headaches. Denies aspirin use.

Allergies: codeine (nausea/vomiting). No known food allergies.

Past Medical History (PMH): He was diagnosed with Stage 2 hypertension a year ago. Also diagnosed with hyperlipidemia last year. Denies regular blood pressure monitoring, history of coronary artery disease, or previous chest pain treatments. Formerly had a heavy EKG but the last one done 3 months ago was normal. He sees his primary care provider every 6 months.

Past Surgical History (PSH): Denies any previous surgeries or blood transfusion.

Sexual/Reproductive History: Heterosexual.

Personal/Social History: Married with two children, the wife is 50 years old and well. Drinks 2 to 3 beers per week although he does not use tobacco or illicit drugs. Has not exercised regularly for 2 years. Unsure of salt intake. Diet mainly consists of granola bars, turkey subs, grilled meat, and veggies. Reports a daily water intake of 1 liter and 1 to 2 cups of coffee daily. No unusual stress was noted.

Immunization History: The last dose of TDAP was 10/2014 while his influenza vaccination is up to date.

Significant Family History: Father had hypertension, hyperlipidemia, and obesity but died at 75 years due to colon cancer. His mother is 80 years old but has type 2 diabetes and hypertension. His brother deceased at 24 years as a result of a motor vehicle accident. His sister is 52 years old and has type 2 diabetes and hypertension. Maternal grandfather experienced a heart attack at the age of 54 years while maternal grandmother died of breast cancer at the age of 65 years. Paternal grandmother succumbed from pneumonia at the age of 75 years while paternal grandfather died aged 85 years due to “old age.” He has a healthy son aged 26 years and an asthmatic daughter aged 19 years.

Review of Systems:

General: Denies fever, chills, weight loss, increased sweating, recent illness, or fatigue.

HEENT: No blurring of vision, hearing problems, runny nose, sore throat, or difficulty in swallowing.

            Cardiovascular/Peripheral Vascular: Denies dizziness, palpitations, peripheral edema, history of angina, or circulation problems

            Respiratory: No cough, shortness of breath, wheezing, or sputum.

            Gastrointestinal: No nausea, loss of appetite, constipation, diarrhea, abdominal pain, bloating, or vomiting.

            Musculoskeletal: No joint pain, swelling, stiffness

Hematological: No anemia, easy bruising, and bleeding.

            Psychiatric: Denies anxiety, hallucinations, or depression.