Physician Internal Medicine H&P     Signed Date of Service:  01/26/22 1750 Creation Time:  01/26/22 2224     Expand All Collapse All     Hide copied text  Hover for details   History and Physical   Attending Physician: Privacy   Date of Admission: 1/25/2022     Source of Information: Pt and chart review    History of Present Illness: The patient is a 60y.o. male who presents for chest pain left sided sharp in nature. Pt has had similar pair over the past several years. Pt also had a syncopal episode 1 week ago , none prior   Positive bilateral upper extremity  Numbness progressively worse over six months   Additionally night sweats beginning 8 days ago  And declining        Past Medical History: Diagnosis Date ? Anxiety   ? Depression   ? Pneumonia     History reviewed. No pertinent surgical history.  Prescriptions Prior to Admission Medications Prior to Admission Medication Sig Dispense Refill Last Dose ? busPIRone (BUSPAR) 15 MG PO tablet take 15 mg by mouth once every morning.     1/25/2022 at Unknown time ? HYDROcodone-acetaminophen (NORCO) 10-325 MG PO Tab take 1 Tablet by mouth 3 times daily as needed for FOR PAIN.     1/25/2022 at Unknown time ? meloxicam (MOBIC) 15 MG PO Tab take 15 mg by mouth once every night at bedtime.     1/24/2022 at Unknown time ? sertraline (ZOLOFT) 100 MG PO Tab take 100 mg by mouth once every morning.     1/25/2022 at Unknown time ? tamsulosin (Flomax) 0.4 MG PO Cap take 0.4 mg by mouth once daily. Take 30 minutes after the same meal each day.     Unknown at Unknown time ? traMADol (ULTRAM) 50 MG PO Tab take 50 mg by mouth once every night at bedtime.     1/24/2022 at Unknown time    No Known Allergies  Family History No family history on file.   Social History    Socioeconomic History ? Marital status: Single Tobacco Use ? Smoking status: Current Every Day Smoker     Packs/day: 0.50  Previously up to 2 packs per day>15 years Substance and Sexual Activity ? Alcohol use: None currently previously heavy ? Drug use: No     Review of Systems: Constitutional:  Denies fever or chills  Eyes:  Denies change in visual acuity  HENT:  Denies nasal congestion or sore throat  Respiratory:  Denies cough or dyspnea  Cardiovascular: admits chest pain denies SOB, or edema  GI:  Denies abdominal pain, nausea, vomiting, constipation or diarrhea  GU:  Denies dysuria, hematuria Musculoskeletal:  See chief complaint tIntegument:  Denies rash + multiple tatoo Neurologic:  Denies headache, focal weakness + sensory changes see chief complaint Psychiatric:  Denies depression or anxiety     Physical Exam: Vitals: Blood pressure 122/60, pulse 63, temperature 97.9 °F (36.6 °C), temperature source Axillary, resp. rate 18, height 162.6 cm (5' 4"), weight 65.8 kg (145 lb), SpO2 97 %.   Body mass index is 24.89 kg/m². No intake or output data in the 24 hours ending 01/26/22 2228   General:Alert, awake, not in acute distress, nontoxic in appearance HENT: No nasal drainage, external ears appear normal, mucous membranes moist. Eyes: PERRLA, no icterus, no pallor.  Neck: No lymphadenopathy or thyromegaly, trachea midline, no carotid bruits. Cardiovascular: Regular rate and rhythm, no murmurs, rubs or gallops, no peripheral edema. Pulmonary/Chest: No use of accessory muscle, chest was clear to auscultation bilaterally, no wheezing, no crackles.diminished BS A&P Gastrointestinal: Abdomen was soft, non-tender, non-distended, no masses felt, no hepatosplenomegaly. Musculoskeletal: Noclubbing or cyanosis, full range of motion in all extremities. Neurological: No focal motor or sensory deficits. DTR's are 2+ and symmetric. Skin: No skin rash, no palpable nodules. Psychiatric: Alert and oriented x 3. Appropriate mood and affect. Studies: These were all reviewed and interpreted.     Chief Complaint Patient presents with ? STROKE     numbness on both arms but mainly my left arm x 1 week. ? Fall     1week ago, hit head +LOC, -thinners ? Chest Pain     "x couple days, it woke me up from my sleep",     Patient is a 60y.o. male with history of COPD, hypertension who presents to the emergency department for evaluation of chest pain, left arm numbness. Patient reports that approximate 1 week ago he got up to use restroom in the middle the night. He reports he felt lightheaded and dizzy and passed out while walking. He reports he has experienced intermittent left sided chest discomfort since that time. Described as a pressure sensation that radiates to the left side of the neck. He reports associated numbness of the left upper extremity. Pain is nonexertional in nature and will typically come on at rest. It usually alleviates within a few minutes. Denies associated shortness of breath. Reports intermittent diaphoresis over the last week as well however this is not associated with the chest pain. He denies any facial droop, difficulties with speech, weakness in the upper or lower extremities. Denies any numbness throughout the remainder of his extremities.