Comprehensive Health History and Physical Examination (Name of student) (Name of Institution) Patient Name: Andrew Brown Date: 10 October 2012 Chief Complaint Mr. Andrew is a pleasant 47 year old man. He is complaining of a having chest pains continuously for the past three days…
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It was around six in the evening while he was driving from work when he noticed a change in his body. There was an abrupt pain onset of the pain to his right side which occurred for a small period of time about one to two minutes. He thought that he might have strained while driving and this might have resulted in the pain. The pain slowly moved from the parasternal area towards his neck. This was the first time he experienced such pain and describes his day as a normal day at the office with no strains. He felt tired at this time as the pain continued to radiate upwards. The pain subsided a little when he got home but he felt a discomfort that was accompanied by a shortness of breath. At this time, he was not nauseated or sweating. The pain seemed to disappear immediately he arrived home and rested. Two days ago the pain returned again and this time a little severe than the first episode and lasted close to five minutes. The pain seemed to emanate from the same place as the previous episode. He experienced this twice during the day in the morning and in the evening. In both instances he was not strained but simply walking around in the office. He went home and took a rest again and the pain seemed to disappear completely until today when the pain episode manifested. All this time he was contemplating of seeking medical attention but did not. He never used any pain relievers or any other drug that could ease the pain. The reason for this he says is that the pain seemed to last for a short period of time and would disappear itself or would end immediately he went to rest. This made him think that the pain was as a result of work. The patient says that he did not experience any other symptom apart from the shortness of breath during the pain episodes. There was no dizziness or palpitations. He also says that there was no other exertional dyspnea, orthopnea or paroxysmal nocturnal dyspnea. Interestingly the pain did not alter during movements or during food intake. There was also no palpable pain. He has never been informed of having heart problems. He has never had a problem with his chest before and neither has he ever experienced chest pains in his life. He does not have claudication. However, Andrew was diagnosed with hypertension about 2 years ago. Andrew is not a smoker and has no symptoms of diabetes. He was only diagnosed with the hypertension 2 years ago which he is fully aware of and had a total abdominal hysterectomy and a BSO about a year ago. Andrew has not been on any hormone replacement therapy of late. He also says that their family has a history of premature CAD. He has been monitoring his cholesterol level for quite some time but at present he does not know. Past Medical, Surgical, and Social History Surgical- has no history of surgical operations Medical history Childhood: diagnosed with mumps at the age of 7. No measles, croup, pertussis, rheumatic fever, scarlet or polio. Accidents: Andrew had an accident while at the age of 12 while riding his bicycle. He developed a fracture. At the age of 25 he was involved in a car accident although he survived with bruises. Chronic illnesses: In 2010 he was diagnosed with hypertension and was on medication until last year when he stopped taking the medication due to the drowsy effect they were having on him. In 2008 he was diagnosed with peptic ulcer disease which was successfully treated after three months using cimetidine. Hospitalizations: He was hospitalized at the age of 12 after the accident where he
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