Medical Note

Elaboration Date

TIME MONTH DAY YEAR

4:00 pm September 15 2015
Patient Name: Alicia Acevedo
Birth Date: July 2, 1961

Gender: Female Social Status: Married Occupation: Housewife Religion: Catholic

Place of Origin: Sur Jalisco Place of Residence: Mangillo-Playa

S Chief of Complaint: Ms. Alicia Acevedo is a 54 y/o women having chest pains for the past few days.
U History of Present Illness: This is the first medical check-up for this 54-year-old woman, who says
B she was in good health until 5 days before seeking medical help. She noticed the abrupt
J onset of chest pain which she describes as dull and aching. The pain initiated in the left para-sternal
E area and radiated up to her neck. The first episode of pain one week occurred when she was working
C in the kitchen in the morning. She was working for an hour and started to feel very tired before the
T onset of pain. Her discomfort was accompanied by shortness of breath, but no sweating, nausea or
I vomiting. The pain lasted 5-10 minutes and went away when she rested. Since that initial pain five
V days ago, she has had another episode of pain similar in quality and location to the first episode. Two
E days ago while cleaning her house she had a 15 minute episode of pain, which went away with rest.
At no time has she attempted any specific measures to relieve her pain, other than rest. She describes
no other associated symptoms during these episodes of pain, including dizziness or palpations. She
becomes short of breath during these episodes but describes no other exertional dyspnea, or
orthopnea. She has never had chest pain before and not aware of any heart problems. She was
diagnosed with hypertension 4 years ago. She does not smoke or have diabetes. There is a family
history of CAD, she does not know her cholesterol level.

Family History:
Mother: 76 alive and well
Father: 58, deceased with heart attack.
No brothers or sisters. There is a positive family history of hypertension but no diabetes or cancer.

Past Medical History:

2011: Diagnosed with hypertension and began on unknown medication. Stopped after 6 months due to
drowsiness.

Allergies: Penicillin
Social History: Drink alcohol occasionally, mostly reserved.
Medications: No prescription or illegal drug use.
 Review by Organ Systems:
HEENT: No complaints of headache, change in vision, no nose or ear problems. No sore throat
Cardiovascular: See History of present illness
Gastrointestinal: No complaints of dysphagia, nausea, vomiting, or change stool consistency or color.
Genitourinary: No complaints of dysuria, nocturia, polyuria, hematuria, or vaginal bleeding
Musculoskeletal: She complains of lower back pain, aching in quality approximately once every week.
No other arthralgia, muscle aches or pains.
Neurological: She complains of no weakness, numbness or incoordination.

O Vital Signs:

B Weight: 63-64 kg

J Height: 1.48 m

E BMI: 27.5

C Temperature: 37.3

T Pulse: 93

I Respiratory Rate: 21

V Blood Pressure: 158/95

E Physical Examination:
General: Alicia Acevedo appears alert, oriented and cooperative. She has a pleasant affect.
Skin: Normal in appearance, texture, and temperature.
HEENT: Scalp normal. Pupils equally round. They are reactive to light and accommodation, sclera
And conjunctiva is normal. Tympanic membranes and external auditory canals normal.
Nasal mucosa normal. Oral pharynx is normal without erythema or exudate. Tongue and gums are
Normal.
Neck: Easily moveable without resistance, no abnormal adenopathy in the cervical or supraclavicular
Areas. Trachea is midline and thyroid gland is normal without masses. Carotid artery pulse is
normal
Chest: Lungs are clear to auscultation and percussion both sides. A murmur is heard at the second
Right inter-costal space. There is a third sound at the apex and no fourth sound is heard.
Abdomen: The abdomen is symmetrical without distention, bowel sounds are normal in quality and
Intensity in all areas. No masses or splenomegaly are noted.
Extremities: No cyanosis, clubbing or edema are noted. Peripheral pulses in the femoral, popliteal
Anterior tibial, dorsalis pedis, brachial and radial areas are normal.
Neurological: Cranial nerves two to twelve are normal. Motor and sensory examination of the upper
And lower extremities is normal. Reflexes are normal and symmetrical bilaterally in both extremities.
 Studies: Pulse oximetry, ECG, and chest x-ray

A Chest pain:
S The patient describes her chest pain as dull, aching and exerting type towards the sub-sternal chest.
S This type of chest pain is suggestive of ischemic heart origin. Her hypertension is a risk factor for
E the development of a coronary artery disease. The combination of the patient’s clinical presentation
S and the presence of hypertension make angina pectoris a likely diagnosis for this patient. The pain
S symptoms appear to be increasing and the occurrence of the pain at rest suggests unstable angina
M and hospitalization is indicated.
E Other conditions may also explain her chest pain but are less likely. Gastro-esophageal reflux disease
N typically occurs at night and not associated with exertion. The type of pain associated with GERD is
T described as burning and this patient does not have that or any gastrointestinal symptoms as vomiting
nausea, or abdominal pain, which might have suggested peptic ulcer disease. The possibility of having
valvular disease is suggested by the murmur, especially aortic stenosis, but a normal carotid upstroke
means this murmur is not significant.

P Carefully monitor the patient for any increased chest pain that may indicate a possible myocardial
L infarction. Begin platelet inhibitors such as aspirin to decrease the risk of myocardial infarction, start
A nitrates to decrease the risk of occlusion and to treat symptoms of pain. The nitrates will help lower BP.
N Patient should have her cholesterol checked and should start doing physical activity and changing her
diet to a low-fat diet. Appropriate lab work would include BUN/Creatinine to assess kidney function,
electrolytes and baseline EKG.

Gousia Shoukat