Name: Chandra Murali

Ill Health History

Date of interview: 10/13/2016
Demographic Data: Patient is a 71-year-old Caucasian male living in Peoria, Il USA. He was
born in Tremont, Illinois. He is alert and oriented. His date of birth is August 20, 1945. His
height is 66 and weighs 168 lbs. He is married and lives with his wife at home. He has 2 sons
and a daughter, who live in Peoria, IL except the daughter who lives in phoenix, AZ. Patient has
6 grandchildren.
Patient (initials): KB

Date of Birth: 08/20/1945

Age: 71

Gender: Male

Race: Caucasian Primary Language: English

Marital Status: Married

Birthplace: Tremont, IL

Type of Dwelling: Condominium

Transportation: Car

Occupation: Retired

Insurance: Blue Cross

Source and reliability of information: Patient Information given is reliable and confirmed by
spouse.
CHIEF COMPLAINT: (ill health history only)-Chest Pain
KB is a 71-year-old male having chest pains for the last two weeks. Patient states he was in his
usual state of good health until two weeks prior to admission. Patient states at that time I
noticed an abrupt onset of chest pain like something heavy was on my chest. Upon further
questioning describes pain as dull and aching in character. States pain began in the middle chest
and sometimes radiated up to his neck. The first episode of pain was two weeks ago which
occurred when he was shopping at the store. The pain was accompanied with discomfort and
shortness of breath, States The pain usually lasts 30 minutes to an hour and sometimes occurred
2 to 3 times a day. The pain resolved when he rested. Patient was at his Doctors office when
the current episode occurred-advised by his PCP to go to the emergency room and have the pain
checked out.
HISTORY OF PRESENT ILLNESS: (ill health history only)
Review of chronology of events:
Location: Mid-chest and at time pain radiating to neck.
Duration: lasts about 30 minutes to an hour occurring two to three times a day.
Intensity: rates pain at 6 on a pain scale of 0-10
Quality/Description: like something heavy is on my chest.
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Name: Chandra Murali

2015HealthHistory

Name: Chandra Murali

Aggravating/Alleviating Factors: Patient states Being active for a prolonged times leads to chest
pain and shortness of breath. The pain lasted approximately 30 minutes to an hour and resolved
when patient rested.
Pain Goal: To keep pain at 3 on a scale of 0-10.
PAST HEALTH HISTORY
Previous hospitalizations: In 2002 Patient was hospitalized for Hemorrhoid Surgery.
Medical history
GERD - 07/17/2014
Neuropathy - 07/17/2014
BPH - 07/17/2014
Mastalgia 12/10/2014
Hyperlipidemia - 2014
Serious injuries or disabilities: Patient does not have any known injuries or disabilities.
Surgeries: Surgical history includes Hemorrhoid Surgery -2002
Pregnancies (females): NA
Childhood illnesses: No known childhood illness other than occasional colds. Patient denies:
Measles, Mumps, Rubella, Polio, Diphtheria, Whooping Cough, Scarlett Fever, Viral Pneumonia,
Hepatitis, Jaundice, and Rheumatic Fever, Pertussis.
Immunizations: Patient is yet to get a flu shot for the current year does not recall his
immunizations.
Screening Tests:
Labs :- RBC 5.36 Troponin 1.325
X-ray 10/12/2016
Reason: Chest Pain and Shortness of Breath
Findings:
Heart is not enlarged.
No focal lung consolidation
Calcified granulomas are noted
Blunting if the left costophrenic angle may represent trace plural effusion or pleural thickening
Echo 10/12/2017
Findings:
Left Ventricular cavity normal
Left Ventricular systolic function mildly decreased
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Right Ventricular cavity size decreased
CURRENT MEDICATIONS AND INDICATION
Medications/Alternative Meds/OTC:
Acetaminophen (TYLENOL) 650 mg - Q6H PRN-PO
Atorvastatin (Lipitor) 40mg nightly - PO
Bisacodyl Suppository - 10 mg - Daily PRN - Rectal
Heparin (Hep-lock, Hep-lock U/P) - 54.9 units/kg once-IV
Hydrocodone Acetaminophen (Norco) - 5-325 mg Q4-PO
Magnesium Hydroxide (milk of magnesia)
Metoprolol (Lopressor) - 25mg-2 times daily-prn-PO
Morphine injection SOLN - 1 mg every 2 hrs-IV
Nitroglycerin (Nitrocot) - 0.4mg Once-SL
Pantoprazole (Protonix) - 40 mg- Daily-PO
Polyethylene Glycol (Glycolax, Miralax) - 17mg Daily PRN-PO
Vitamin B12/cyanocobalamin - 500 mcg Daily-PO
Vitamin C 250 mg PO Daily.
Zolpidem (Ambien) - 5mg nightly-PO
Occasional OTC ibuprofen (Advil) for occasional pain or headache.
Allergies: Penicillin- experienced rash and hives on 05/21/2014.
Social History includes alcohol use of 1 or 2 beers each weekend; 1 glass of wine once a week
with dinner. Tobacco use: None at this time. Quit 30 years ago. Smoked half a pack a day for 12
years. No illegal drug use.
FAMILY HISTORY
Narrative description
Father died at the age of 69 years from a heart attack and had type 2 diabetes and hypertension.
Mother died at the age of 72 from cervical cancer and was diagnosed with rheumatism and
hypertension. Two older brothers ages 76 and 74 both in good health. Three children aged 47, 45
and 39 are alive and well. Paternal grandfather: deceased age 92 CVA Maternal grandmother
deceased age 81 MI. No history of TB, psychiatric disorders, kidney, thyroid or lung disease
PERSONAL AND SOCIAL HISTORY
Personal status: Mr. KB is married since the age of 23 to his wife who is 70 y/o and in good
health. States marriage is stable, children doing well. Denies any form of mental, physical, verbal
abuse

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Health habits: Occasionally goes for a walk with wife on the riverfront. Tries to eat
healthy. Does not exercise.
Sexual history: Patient is monogamous and sexually active with wife 2 to 3 times a
week. Has not been involved with any other partner. Patient denies: erectile dysfunction,
sexually transmitted diseases, prostate enlargement, prostate cancer.
Home conditions: Patient lives in a three-bedroom condominium on the 14th floor of a
building with elevator. He has a home helper who comes 3 hours a day two times a week.
They have lived there for the past 7 years.
Occupation: Retired from construction work 14 years ago. No occupational exposure to
inhaled toxins or sick contacts.
Environment: Patient lives in a safe neighborhood and free from any pollution and
environmental dangers wears seatbelts at all times. No motorcycles. Has carbon
monoxide and smoke detectors in home.
Military record: Did not serve in the military
Complementary/alternative health: Not involved in any complementary/alternative health
Patient denies any massages or acupuncture.
Culture/Religious practices: Patient is a Christian and part of the Apostolic church and
very active in Church of God.
ADLs: Patient is able to perform all activities of daily living without any problems. His
current chest pain is a 6/10 that has limited his ADLs.
REVIEW OF SYSTEMS
General health state: Patient denies any fever, chill or fatigue.
Nutrition and Hydration: Patients states that he eats three meals daily. No history of
eating disorders.
Skin, hair, nails: Patient denies any changes in skin pigmentation, temperature, skin
moisture, or skin texture. Denies any rash, moles, abnormal hair growth, warts, nevi,
itching, eczema or excessive sweating.
Head and neck: There is no tenderness over the scalp or neck. Patient denies past head
trauma, head injury, dizziness, syncope, loss of consciousness.
Eyes: Denies eye pain, excessive tearing or visual disturbance. Wears prescription
glasses.
Ears: Denies hearing loss, ear pain, tinnitus or earaches.

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Nose: Patient states he has had no discharge and no obstruction.
Throat and mouth: Denies bleeding gingiva, ulcers, nodules, pain, ST, hoarseness, no
difficulty while swallowing. No lesions or swelling on the tongue.
Breasts: Patient was diagnosed for mastalgia. States there was breast pain and tenderness
with no masses or lumps, unusual secretions.
Thorax and lungs: No history of continuing cough, wheezing, asthma, pulmonary
emboli, pneumonia, TB or TB exposure.
Heart and Neck Vessels: Denies palpitations, PND, orthopnea, syncope, leg pain, edema
or varicose veins. Denies history of murmur. Present chest pain started two weeks ago.
Peripheral Vascular: No history of claudication, gangrene, deep vein thrombosis, or
aneurysm.
Abdominal-gastrointestinal: Patient has no complaints of dysphagia, nausea, vomiting,
or change in stool pattern, consistency, or color. Patient has no complains of epigastric
pain. Patients states that he does have GERD and it bothers him sometimes.
Abdominal-urinary: Patient denies any Urinary Tract Infection, Sexually Transmitted
Diseases, pain, stones, facial edema, incontinence, Does have BPH making it hard to
urinate.
Musculoskeletal: Patient denies
temperature, and muscle weakness.

joint/back pain, stiffness, swelling, increased

Neurological: Patient has no complains of weakness, numbness, or incoordination. Patient

denies any episode of epilepsy, Alzheimers disease, encephalitis, Bells Palsy, headaches,
syncope, memory loss, tremors. Patient was diagnosed with Neuropathy on 07/17/2014,
states does not affect his ADLs and does not have pain. Patient is alert and oriented.
Genitalia: Denies pain or swelling in the genital area.
Anus, rectum and prostate: Patient was diagnosed with BPH in 07/17/2014 causing it
hard to urinate. denies any pain or swelling in the anus or rectum area. Denies
Hemorrhoids.
Endocrine: Denies unexplained weight change, fatigue, heat/cold intolerance or polyuria
Hematological: Patient denies: blood clots, anemia, low RBC count, low WBC count, and
leukemia.

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PSYCHOSOCIAL AND LIFESTYLE FACTORS

Social, cultural and spiritual: Patient is socially active within the community especially
among his church members and is spiritual. States He follows the Culture of Christ and
values the American culture and respects the family values.
Mental health: Denies symptoms of anxiety or depression, mood swings, sleep
disturbances, delusions, or hallucinations.
Human Violence Assessment: Patient has no violent past or incidents. States He and his
family are peaceful and god loving who try help anybody in need.
Sexual History and Orientation: Patient is sexually active with his wife and hasnt had
any other sexual partner. Patient is doesnt believe in same sex marriage.
SUMMARY OF SIGNIFICANT FINDINGS (Include both strengths and limitations):
This 71year old Male Patient with no history of congestive heart failure, or coronary artery
disease risk factors of hypertension presents, with substernal chest pain. Upon Admission in the
emergency room he was found to be in sinus tachycardia, with no JVD. There were EKG
changes indicate an acute myocardial infarction with blockage in one of the arteries, and the labs
shows elevation of CPK and troponin. The pain symptoms appear to show an occurrence of pain
when active suggests this fits the presentation of acute MI, and hospitalization was indicated by
the attending physician to undergo a coronary angiogram which confirmed the blockage of an
artery. A Cardiac catheterization procedure was performed and a stent placed. Patient is weak
after the procedure. He is resting with his wife at bedside. The following findings exist presently
GERD - 07/17/2014
Neuropathy - 07/17/2014, BPH - 07/17/2014, Mastalgia 12/10/2014 and Hyperlipidemia - 2014
were diagnosed. Patient is alert and oriented and has a good support of his family and friends.

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