Sample Report: History and Physical: Myocardial Infarction
IDENTIFICATION: The patient is a male in his mid-30s who works as a heavy equipment construction worker. He was admitted from the emergency department.
CHIEF COMPLAINT: Severe chest pain, with radiation into the left neck and down the left arm.
HISTORY OF PRESENT ILLNESS: The patient was brought to the emergency department by ambulance after awakening at approximately 4:30 a.m. with squeezing substernal chest pain that radiated into the left side of his neck and down his left arm. The pain was associated with dyspnea and diaphoresis. He states that the pain decreased in intensity after taking 3-mg nitroglycerin sublingual that was given to him by a member of the emergency medical team. He admits to having similar chest pain about a month ago after working out at the gym. The pain subsided after resting. He did not seek medical advice following the incident. He denies episodes of tachycardia, bradycardia, orthopnea, or pedal edema. He denied smoking when seen by me in August of last year; however, he now admits that he has smoked 2 packs of cigarettes per day for 18 years. He has attempted to quit on numerous occasions but has been unsuccessful. He rarely consumes alcohol and denies illicit drug use. The family is not attentive to a low-fat diet. He does not have a diagnosis of hypertension or diabetes. He did not follow through with his last lab work request, so there is no current cholesterol value.
PAST MEDICAL HISTORY: He has a long history of asthma. He was hospitalized in 2001 with pneumonia. He had a false-positive TB skin test in 1990 for which he was treated with Rifampin.
PAST SURGICAL HISTORY: Appendectomy in 1988, vasectomy in January 2001.
MEDICATIONS: The patient is currently on no medications.
ALLERGIES: The patient has no known medication allergies.
FAMILY HISTORY: The patient's father died at age 40 of myocardial infarction. His brother underwent bypass surgery last year at 37 years old. His mother is alive and in reasonably good health at age 70.
REVIEW OF SYSTEMS: Negative otherwise.
PHYSICAL EXAMINATION: GENERAL: The patient is lying quietly in bed. He appears anxious about his condition. VITAL SIGNS: Blood pressure 180/110, pulse 110 and steady. SKIN: He appears pale; the skin is somewhat clammy to touch. HEENT: Appears normal. CHEST: Lungs are clear to percussion and auscultation. Breath sounds are normal. HEART: There is ST elevation in leads V4, V5, and V6 on electrocardiogram. There is a harsh holosystolic murmur at the left lower sternal border, with midsystolic peak. S1 and S2 are soft.
ABDOMEN: The abdomen is flat and nontender. Bowel sounds are normal, and there are no bruits.
GENITALIA: Appear normal. MUSCULOSKELETAL: Tattoo on right forearm.
EXTREMITIES: No extremity edema or tenderness.
NEUROLOGIC: Not done at this time.
ASSESSMENT: The patient has been under considerable stress lately. His company has recently announced that they will be decreasing their workforce by approximately 20 percent. His son has recently been diagnosed with a mental disorder of some sort, possibly schizophrenia. The patient was moved to coronary care unit for close monitoring. A cardiac catheterization is ordered for this afternoon.
ADMITTING DIAGNOSIS: Myocardial infarction.