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HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT
Chest and left arm pain.

HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old white male with no history of cardiac problems who presented to the emergency room with the chief complaint of chest and left arm pane.

PAST MEDICAL HISTORY: He has a history of a hiatal hernia with reflex. His past surgical history include a hemorrhoidectomy, appendectomy, tonsillectomy and right arm amputation below the elbow from an accident three years ago. Patient wears a prostatic.

SOCIAL HISTORY: The patient smokes one pack per day and drinks 3-4 bears per night. He is married and has three children, all in good hearth. He works as a manager for K-Mart.

FAMILY HISTORY: Father died of a heart attack. He had bypass surgery a few years after his death. Mother is alive and has diabetes.

REVIEW OF SYSTEM
HEENT: Normal hearing. No vision problems.
RESPIRATORY: Gets “chest colds” unusually once per year, with productive couch. No shortness of breathe or wheezing.
CARDIOVASCULAR: Not prior history of problems. No palpitations, chest pain, syncope or regular heart beat.
GI: As noted, hiatal hernia with reflux, prior hemorrhoidectomy. No diarrhea, nausea, vomiting, hematemesis or other problems.
GU: Has a good urinary steam. No incontinence.
ORTHOPEDIC: Occasional arthritis symptoms in the knees. Prior amputation of the left arm below the elbow from an accident.

PHYSICAL EXAMINATION
Temperature is 98.6, pulse is 80 and regular. Respiration are 15. Blood pressure is 250/100.
GENERAL: Patient appears in moderate distress, clutching his chest, appearing pale and diaphoresis.
HEENT: Head is normal cephalic and traumatic. Pupils are equal, round and reaction to light and accommodation. Ears normal. Throat benign.
SKIN: There are two lesions noted on the face, suspicious for basil cell carcinoma. Patient notes they have been presence for a number of years.
NECK: Supply. No bruits. No JVD. No nuchal rigidity.
CHEST: Lungs are clear to osculation and percussion.
HEART: Regular rate and rhyme with a normal S1, S2. PMI is heard beat at the midclavicular line, 5th intercostal space. No heaves, lifts, thrills, rubs or murmurs.
ABDOMEN: Soft and benign. No masses or organomegaly noted.
GENITALIA: Normal adult male. Testes are distended and normal.
RECTAL: Prostate is 1+ and larged. No blood noted.
EXTREMITIES: The right arm is amputated above the elbow. There is a prosthesis in place. The left arm is normal in appearance. There are no clubbing, cyanosis or edema. Good lower extremity peripheral pulses felt bilateral.
NEUROLOGIC: No deficits noted.

LABORATORY DATA
EKG reveals ST-T wave changes in the anterior leads suggestion of a cute myocardial infraction. Potable chest x-ray is of poor quality with poor inspire but is clear. Cardiac enzymes and other CCU labs are pending at this time.

ADMITTING DIAGNOSES
1. Chest pain. Rule out myocardial infarction.
2. Right arm amputation, below the elbow.
3. Three lesions of face, suspicious for basal cell carcinoma.
4. Smoker.
5. Hiatal hernia with reflux.
6. Status post hemorrhoidectomy, appendectomy, tonsillectomy.

PLAN: She will be admitted to the CCU and cardiac workup will comment. Will ask for cardiology consultation.
 

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