Brian foster: Chest Pain shadow health, soap note, Episodic Visit

Brian foster Chest Pain shadow health-soap note, Episodic Visit Your Name: Brian Foster Source and Reliability: Self, reliable as historian SUBJECTIVE Chief Complaint (CC): “I have been having some troubling Chest Pain (CP) now and then for the past month” History of Present Illness (HPI): Patient is a 58 y/o Caucasian male presenting with complaints of intermittent chest pain that started about a month ago which has happened 3 times in the past month. Patient has not sought emergency care for the chest pain as he states it is triggered by exertion and resolves “after a few minutes” of rest. When chest pain occurs, he rates 5/10 but currently pain is 0/10 as chest pain is not currently present on this visit. Denies pain radiating. No c/o of pain in arm, shoulder, neck, back or jaw. The only trigger he can associate chest pain with is activity. Denies heartburn, GERD/reflux, abdominal pain, bloating or any GI symptoms to correlate this pain with. He denies taking any medication for chest pain as it resolves with rest, denies taking aspirin, takes Tylenol for minor aches and pains unrelated to chest pain. Denies SOB. Denies stressors. Patient is only stressed about figuring out source of chest pain. Past Medical History (PMH): HLD- Diagnosed about a year ago HTN (Stage II)-Diagnosed about a year ago Past Surgical History (PSH): None Medications: Lisinopril 20 mg daily PO, atorvastatin 20 mg HS PO, Omega-3 Fish Oil 1200 mg PO BID Tylenol for minor aches and pains (PRN and not daily) Allergies: Codeine (Nausea and Vomiting) Immunizations: Tdap 10/2014, Influenza this season Family Hx: • Father: HTN, HLD, obesity, passed away from colon CA at age 75 • Mother (80 y/o): Type 2 DM, HTN • Daughter (19 y/o): Asthma • Son (26 y/o): No current health problems • Brother: Fatal MVA 24 y/o • Sister(52 y/o): DM2, HTN • Maternal grandmother: passed away of pneumonia at age 78 • Paternal grandfather: passed of “old age” at 85 y/o Social Hx: Patient married for 27 years to wife, 2 grown children (19 and 26 y/o). Denies stressors at hoe and at work. Only stress admitted to this visit of stress of this recurrent chest pain. Goes to annual physicals which he had about 3 months ago where he did have an EKG and he stated that they said it was normal. Also had a stress test about a year ago which he stated all the doctors ever tell him are “everything looks good”. Drinks 2 cups of coffee per day. Denies current exercise however, he used to regularly exercise before bike got stolen about two years ago and would like to get another bike to begin again however, he wants to clear it with doctor due to current bouts of chest pain. Typical breakfast is instant breakfast shake and granola, for lunch a turkey sub or an occasional Italian sub, and dinner is typically grilled veggies and meat of some sort. For hobbies patient likes sports and to fish, he also occasionally goes to his son’s body building camps when he can and repair small electronics.