work due ASAP

How can I help you today?

I have been having chest pain.

Does your chest feel tight or heavy?

I would say heavy, but it’s not in one area, it’s all over my chest.

When did the pain start in your chest?

About 5 days ago.

What are the events surrounding the start of your chest pain?

It first started when I was walking about the neighborhood on my afternoon walk about 5 days ago.

Does anything ma ke the pain in your chest better or worse?

When I walk too fast it seems to make it worse. When I stop and tae a rest , it goes almost completely away within 3-5 mins.

What does the pain /discomfort in your chest feel like?

More of a pressure sensation.

Where more precisely is the pain in your chest?

Its all over my chest, not one place in particular.

Does the pain in your chest radiate someplace else? where?

Nope, just all around my chest.

How severe (1-10 scale) is the pain un your chest?

Like a 6 when it happens. But right now, it’s a zero.

Doe the pain in your chest come and go?

Yes, when I exercise or exert myself it happens. When I stop and rest, it goes away.

How long does your chest pain last?

I would say less than 5 mins, may be only 2 or 3 mins if I immediately stop and rest.

What treatments have you had for the pain in your chest?

No meds. I just take little rest breaks which seems to help it go away.

What symptoms is the nost distressing for you?

The chest pain, its why I’m here.

Has anyone else you know developed these symptoms?

No

Tell me how that makes you feel?

Scared

How does this affect your life?

Well, I have been having to take breaks a lot during my afternoon walks and had to cut a few walks short because of it.

Do you have any other symptoms or concerns we should discuss?

Sometimes I also get winded and tired.

Can you tell me about any current or past medical problem you have had?

I have high blood pressure, high cholesterol, some type of murmur they call aortic stenosis, and heart disease. I guess the official name is coronary artery disease.

Do you have any mental health problems?

No

Have you seen another health care provider for this situation or concern?

I saw my primary care 5 months ago. Does that count? I wasn’t having the chest pain them though.

Do you have high Blood pressure?

Yes, I take medications for that.

Do you have high cholesterol?

Yes. I take red yeast rice for that. My primary care wanted to start me on some sort of prescription cholesterol medication a few months ago, nut I didn’t want to take it yet.

Do you have heart disease and/or have you ever had heart attack?

I’ve never had a heart attack. I have coronary artery disease. My primary care wanted to send me to a cardiologist a few months, but I wasn’t interested.

Have you had a lot of unexplained illness?

Nope

Do you have diabetes?

Nope

Cancer?

No

Stroke?

No

Bleeding disorder

No

Blood clots

No

Liver problems

No

Sleep apnea

No

Complications at birth?

No

Heart murmur?

Yes. I got some sort of test a few months ago to check up on that. They called it aortic stenosis.

Cardiologist?

No. my primary care wanted to refer me to one after they found the murmur several months ago, but I didn’t want to go.

STI/HIV

Why are you asking that?

Any previous medical, surgical or dental procedures?

I had my gallbladder removed 20 years ago. About 11 years ago I had surgery to get my mouth for dentures.

Have you had any heart surgeries or stent placement?

No. I do have coronary artery disease though. My primary care wanted to send me to a cardiologist a few months ago, but I wasn’t interested, specifically because I don’t want procedures or anything.

Have you ever had general anesthesia?

Yes, with both surgeries.

Have you ever had complications from general anesthesia?

No

Have you had colonoscopy?

Yes 10 years ago and everything was fine.

Have you had any recent blood or lab tests? What were the results?

At my annual check up a few months back. I think its in my record.

Have you ever had an ECG?

Yes , with my check up a few months back. They said it looked fine.

Have you ever had CT scan?

I think for my gall bladder before I had it removed.

Recently any IV or intra- arterial dye?

No

Dialysis

No

Have you had a stress test, if so when and where?

No

Hab eyou ever particilared in a sleep study?

No

Have you ever been hospitalized?

Just the one night when I had my gallbladder removed I was discharged home the next day.

Habe you had any significiat traumatic injuriesor accidents?

Nope

Were there any complications when you were in =utero?

No

What childhood illness habe you had?

The usual coughs, colds and tummy aches. Nothing remarklble

Are you taking any prescription medications?

Yes. Let me think… lisinopril 20 miligrams once a day and ASA 81 mg once a day.

Are you taking over the counter or herbal medications?

Yes, red yeast rice 600 milligrams daily.

Are you having any problems with meds?

No

Can you provide the dosage and frequency of each medication you are taking?

Yes. Let me think… lisinopril once a day and ASA 81 mg once a day. The red yeast rice is 600 mg daily.

When did you last take thesemds

This morning.

Have you ever used hormone therapy …

No

Birth control meds

No

Steroids

No

ALLERGIES

NONE

Are your immunication up to date?

Yeah

Flu shot/covid shot/PNA vaccine/DPT/Herpes

Yes

HPV vaccine

Yes

Do you have periods

No I don’t have periods anymore

Tell me family history

Mother passed at 92- had high cholesterol

Father who passed away at 89 – had COPD

My son 45 has no health issues .

My son has two wonderwul childrena that I get to watchevery week.

Family hx of heart disease

When I walk too fast it seem to maje it worse. When I stop and take a rest, it goes almost completely away within 3-5 minutes

What doe syour pain /discomfirt in your chest feels like?Seqeezing? pressure? Crusing?

More aof a pressure sensation

Where more precisely is the pain in your chest?

All over my chest, not one place in particular.

Does the pain in your chest radiate some place else?wheere?

None, ultrasound my chest

How severe is the pain

6/10 but zero pain right now.

Does pain come and go?

Yes wben I execrecise or exert myself it happens, wheni stop and rest , it goes away.

What tx have you had for the pin in your chest?

No meds

Does your chest feel tight?

I would say heavy, but not in one area. Its all over my chest.

What symptoms is the most distressing for you?

Chest pain

Tell me how that makes you feel?

Sacred.

Do you have regular period?

I don’t have periods anymore.

Has anyone in your family struggled with mental health issues?

No

Tell me about your work?

Im retired. I get to babysit my grandchildren now through.

Where and with whom you are living?

My husband.

Do you drink alcohol?

No I don’t drink.

Do you now or have every smoked or chewed tobacco?

No I don’t.

How is yor family and your family life?

Pretty good I guess.

Are you sexually active?

Yes, with my husband.

Do you have unusal heartbeats?

No I would say more chest pain than anything.

Do you awaken at night SOB?

No

Are you shortness of breath?

Yes, sometimes, especially when ,y chest pain starts up.

Excericise /preventive hea;th

I do walkaround the neighbourhoof in the afternoons as long as its not raining.