report 35

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Medicine

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Jan 9, 2024

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John “Jack” Blake HISTORY Mr. Blake is a 60-year-old white male who states that he has had 4 heart attacks since 1973. He has had chronic amniocytes most recently treated with Isordil with guidosept. CHIEF COMPLAINT He has been relatively pain-free until yesterday when he had anginal tight pain, pre-cordial, and radiating into the arms. Each episode lasting 1 to 5 minutes and relieved by nitroglycerin. PRESENT ILLNESS He had 10-12 episodes yesterday. In addition, he noted almost continuous sweating throughout the day, but no nausea or vomiting. He also ran a temperature of 102 degrees yesterday and 104 degrees today. He had one shaking chill today. He denies ear, throat, and abdominal pain, dysuria, and stiffness of the neck, but he has had a headache for 2 days, frontal in nature, and he feels a feeling of pressure over both of his eyes. After being admitted to the hospital with a possible respiratory infection, an EKG showed changes in electrocardiogram consistent with acute mild cardio infraction, and the patient was taken to ICU. PAST MEDICAL HISTORY OPERATIONS: Appendectomy as a child. DISEASES: Usual childhood diseases. ALLERGIES: No allergies. HABITS: Is a pipe smoker and social drinker. MEDICATIONS: Coumadin 5 mg per day, Isordil and Valium. REVIEW OF SYSTEMS GENERAL: No joint pain or rash. HEENT: No convulsions, chronic ear, or throat infections. No history of sinusitis. CHEST: Shortness of breath only on climbing hills. No PND, orthopnea, or palladium. ABDOMEN: No nausea, vomiting, diarrhea. The patient tends to be constipated with stools like “toothpaste.” He also had hemorrhoids. GU: Nocturia x1. No dysuria or hematuria. RE: John “Jack” Blake December 12, 2023 Page 2

PHYSICAL EXAMINATION GENERAL On physical exam I found a wirily, talkative, alert white male in no apparent distress, slightly flushed. Pulse 70. SKIN: Clear except for slight flush and feeling of warmth and moisture. HEENT EARS: Tyms intact. EYES: Sclera clear. PERRLA. No cataracts noted, however both eye grounds are slightly hazy. Fundie and vessels appear to be normal through the haziness. MOUTH: No extradites. NECK: The neck is supple, no nodes, no venous extension, no thyroid megaly. CHEST LUNGS: Clear to PNA HEART: PMI within normal limits. Normal sinus rhythm. No rubs, murmurs, thrills or gallops heard. BACK: No vertebral tenderness. However, there is a left sided CVA tenderness at times. ABDOMEN: Soft, none tender. Good bowel sounds, no breweries. Liver not enlarged, no hepatojugular reflux, no masses. GENITALIA: Normal circumcised male. EXTREMITIES: No clubbing, cyanoses, or edema. Reflexes at 2 plus and equal, Babinski down. IMPRESSION 1. Acute mild cardial infraction 2. Fever of unknown etiology. Rule out acute bronchitis, pneumonia, septicemia. RE: John “Jack” Blake December 12, 2023 Page 3

Jane A. Walter, MD SW D: September 1, 1980 T: December 12, 2023

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