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MEDICAL HISTORY FORM

History and Physical Examination Comments

Patient Name: Gusqui, Juan

Date: 28/10/2018

Referral Source: Emergency department

Data Source: Patient’s daughter

Chief Complaint & ID: Mrs. Gusqui is an 80 y/o male whose chief complaint is chest pains
for the last week.

HISTORY OF PRESENT ILLNESS

Patient is an 80 y/o man complaining of chest pains for the last week, the pain began in the
left para-sternal area and radiated up to his neck accompanied by shortness of breath, but no
sweating, nausea or vomiting

Since the initial pain one week ago he has had 2 additional episodes of pain, similar in quality
and location to the first episode

At no time has he attempted any specific measures to relieve his pain, other than rest.

He was diagnosed with hypertension 3 years ago.

PAST MEDICAL HISTORY

Diagnosed with hypertension and began on unknown medication. Stopped after 6 months
because of drowsiness

Allergy: Penicillin; experienced rash and hives 5 years ago

SOCIAL HISTORY

Alcohol use: 1 or 2 beers each weekend.

Tobacco use: None.

Medications: No prescription or illegal drug use.

FAMILY HISTORY

polyuria. There is a positive family history of hypertension. Pupils equally round. nose or ear problems. consistency. vomiting. numbness. which he notices primarily at night. Carotid artery upstroke is normal bilaterally without bruits. Oral pharynx is normal without erythema or exudate. or color. Skin: Normal in appearance. General: Patient appears alert. 4 mm. nocturia. oriented and cooperative. Tongue and gums are normal. deceased. reactive to light and accommodation. Nasal mucosa normal. . texture. nausea. or incoordination. Fundoscopic examination reveals normal vessels without hemorrhage. heart attack. approximately twice a month. and temperature HEENT: Scalp normal. Tympanic membranes and external auditory canals normal. Neurological: He complains of no weakness. Trachea is midline and thyroid gland is normal without masses. or change in stool pattern. sclera and conjunctiva normal. no abnormal adenopathy in the cervical or supraclavicular areas. approximately once every week. Gastrointestinal: No complaints of dysphagia. Genitourinary: No complaints of dysuria. he complains of epigastric pain.Father: 54. aching in quality. burning in quality. Jugular venous pressure is measured as 8 cm with patient at 45 degrees. REVIEW OF SYSTEMS HEENT: No complaints of headache change in vision. or sore throat. Musculoskeletal: He complains of lower back pain. PHYSICAL EXAMINATION Vital Signs: Blood Pressure 168/98 Pulse 90 Respirations 20 Temperature 37 degrees. hematuria. Neck: Easily moveable without resistance.

liver span is 8 cm by percussion. and radial areas are normal. brachial. popliteal. dorsalis pedis. Neurological: Cranial nerves II-XII are normal. DIAGNOSTIC Uncontrolled high blood pressure . bowel sounds are normal in quality and intensity in all areas. supraclavicular. Peripheral pulses in the femoral. Reflexes are normal and symmetrical bilaterally in both extremities. Nodes: No palpable nodes in the cervical. Extremities: No cyanosis. A grade 2/6 systolic decrescendo murmur is heard best at the second right inter-costal Abdomen: The abdomen is symmetrical without distention. PMI is in the 5th inter-costal space at the mid clavicular line. a bruit is heard in the right paraumbilical area. No masses or splenomegaly are noted. anterior tibial. axillary or inguinal areas. Motor and sensory examination of the upper and lower extremities is normal.Chest: Lungs are clear to auscultation and percussion bilaterally except for crackles heard in the lung bases bilaterally. or edema are noted. clubbing. Gait and cerebellar function are also normal.