Graded A+
Chief Complaint - -Mr. Larsen is a 48-year- Lisinopril 10 mg P.O. daily for hypertension. Last
old White man who presented to the ED at 6 AM dose: yesterday
with a perceived cardiac complaint; he reports Fish oil 1 tab daily for high cholesterol. Last dose:
being exhausted, scared and unable to relax yesterday
from last night.
Family History - -Mother, living, high
History of Present Illness - -Hx of HTN, cholesterol
hyperlipidemia, and osteoarthritis, presented in Father died of lung cancer, had HTN, deceased
the ED this morning with complaints of age 50
exhaustion, anxiety, terror, and tachycardia No known family history of mental illness
which started last night 3 AM. Patient reports that
the worry has been around since he was
diagnosed with HTN (a year ago), but becomes Social History - -Employment: Currently
worse last night. He states that he feels like he is employed as a postal clerk.
choking, his body is sweating, shivering and he Marital Status: Single, has no children, living
has been unable to control his fear since 3 AM. alone.
He says that he is scared about everything, Tobacco: He denies past or present tobacco use.
especially his hypertension; he tried to take a Alcohol/Illicit Drug Use: He drinks a beer or two
deep breath several times to feel calm but did not on the weekend, he denies any illicit drug use.
work. He states that he came to the ED because
he thought he was having a heart attack from his
hypertension. He says that the anxiety causes Review of Relevant Systems - -GENERAL:
him to skip work, prevents social interaction and Fatigue, and diaphoresis. Negative for fever,
that it affects his concentration and sleeping night sweats, or purposeful changes in weight.
patterns. He denies any chest pain, fever, mood RESPIRATORY: Shortness of breath.
changes, or suicidal thoughts. CARDIOVASCULAR: Palpitations. Negative for
chest pain, or edema.
NEUROLOGICAL: Reports weakness. Negative
Allergies - -Codeine for fainting, numbness/tingling, dizziness,
frequent headaches, falls, or changes in
coordination or memory.
Past Medical History - -HTN since age 47 PSYCHOLOGICAL: Anxiety, changes in
Osteoarthritis since age 46 concentration, and sleeping pattern. Denies
Hyperlipidemia since age 45 depression, suicidal thoughts
Past Surgical History - -Total knee
replacement at age 48.
Medication History - -Atorvastatin 20 mg
P.O. daily for high cholesterol. Last dose:
yesterday
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