C.D is a 55-year-old African American male who presents to his primary care provider with a 2-day history of a headache and chest pressure.
PMH
Allergic Rhinitis
Depression
Hypothyroidism
Family History
Father died at age 49 from AMI: had HTN
Mother has DM and HTN
Brother died at age 20 from complications of CF
Two younger sisters are A&W
Social History
The patient has been married for 25 years and lives with his wife and two children. The patient is an air traffic controller at the local airport. He has smoked a pack of cigarettes a day for the past 15 years. He drinks several beers every evening after work to relax. He does not pay particular attention to sodium, fat, or carbohydrates in the foods he eats. He admits to “salting almost everything he eats, sometimes even before tasting it.” He denies ever having dieted or exercised.
Medications
Zyrtec 10 mg daily
Allergies
Penicillin
ROS
States that his overall health has been fair to good during the past year.
Weight has increased by approximately 30 pounds in the last 12 months.
States he has been having some occasional chest pressure and headaches for the past 2 days. Shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis.
Reports some shortness of breath with activity, especially when climbing stairs and that breathing difficulties are getting worse.
Denies any nausea, vomiting, diarrhea, or blood in stool.
Self treats for occasional right knee pain with OTC Ibuprofen.
Denies any genitourinary symptoms.
Vital Signs
B/P 190/120, HR 73, RR 18, T. 98.8 F., Ht 6’1”, Wt 240 lbs.
HEENT
TMs intact and clear throughout
No nasal drainage
No exudates or erythema in oropharynx
PERRLA
Funduscopy reveals mild arteriolar narrowing without nicking, hemorrhages, exudates, or papilledema
Neck
Supple without masses or bruits
Thyroid normal
No lymphadenopathy
Lungs
Mild basilar crackles bilaterally
No wheezes
Heart
RRR
No murmurs or rubs
Abdomen
Soft and non-distended
No masses, bruits, or organomegaly
Normal bowel sounds
Ext
Moves all extremities well
Neuro
No sensory or motor abnormalities
CN’s II-XII intact
DTR’s = 2+
Muscle tone=5/5 throughout
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