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Original Question
Case Study Chief complaint Left side chest pain since last night. • Also has had a clear nasal discharge • Had some virus a few weeks ago. Saw a doctor in the ER and he said it was an upper respiratory infection. • I was not given any medications and to stay hydrated, Tylenol as needed. • Return if there are any problems Past Medical History • Denies any past medical history Medical problems • Appendectomy in college Surgical history • States vaccines as a child were done. Has not had any boosters • Flu Shot last fall (2024) Immunizations • Just when he had his appendectomy Hospitalizations • Sees his doctor about once every year or so. Usually goes to urgent care clinic when needed Preventive care history • Has tried Tylenol for this pain with no relief Medications • Penicillin Family & Social History • Father 62 alive; history of heart attack and bypass surgery. • Mom 58, alive diabetes type II • Paternal grandfather 85, heart problems • Paternal grandmother 83; arthritis • Maternal grandfather dead, heart attach • Maternal grandmother 82 history of stroke • Brother 38 alive and well • Sister 35 diabetes Type II but well otherwise Family history • Works as a teacher in high school, teaches math • Graduate of Texas A&M • Smokes 1 pack per day for 15 years • Drinks socially Review of systems CONSTITUTIONAL: Fatigue for about a week EYES, EARS, NOSE, THROAT: Runny nose, but getting better RESPIRATORY: Occasional cough; pain worse in chest with breathing CARDIOVASCULAR: ches
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