(Solution) iHuman Case Study Jacob Abraham CC Burning chest discomfort

iHuman Case Study Jacob Abraham CC Burning chest discomfort/ IHuman Case Study: Jacob Abraham, 58y/o Male CC: Reason for encounter: “I’ve been having some chest discomfort” HPI: The patient is a 58-year-old male who presents to the clinic with chest discomfort that began one week ago. The patient stated that he was asleep, and the chest pain woke him up at night. The chest pain is in the mid-sternal area. The pain lasts approximately 30 minutes of longer. He reports having 4 episodes of chest pain already. He describes the pain as a burning and denies experiencing chest pain in the past. He rates the pain as a 4-5/10. His chest pain occasionally moves up to his neck area. Denies hx of heart burn. ROS: General: denies weight loss, malaise, or night sweats. The patient is afebrile, and he is good historian for his health hx HEENT/ Neck: Radiating pain to the neck area around Adams apple. Cardiovascular: chest pain; denies heart palpitations, SOB or lightheadedness Respiratory:chest pain; denies SOB or cough ; Denies changes with breathing. Takes shorter breaths when the pain is present Gastrointestinal:consumes unhealthy meals, alcohol, and coffee Genitourinary:negative Musculoskeletal/ Osteopathic structural examination:negative Neurologic:negative Integumentary/ breast:negative Psychiatric SOAP note for ihuman Jacob Abraham case- 58 y/o male - 6 ft, 216 lbs presenting with c/o burning chest discomfort. PMH: HTN x15 years, on Lopressor 50 mg QD. Borderline hyperlipidemia, borderline obesity Father had MI in his 50's and 60s, died of CVA at 85. Mother Alive and Well at 77