Cardiology intake report
Chief complaint
"Tightness in my chest when I walk uphill."
History of present illness
Central chest tightness for about 6 weeks, brought on by walking uphill or carrying groceries and relieved within 5 minutes of rest. Severity 5/10. No radiation to arm, jaw or back. Mild exertional dyspnea. No symptoms at rest reported. No syncope. No palpitations.
Cardiac risk factors
- Hypertension, diagnosed 2019
- Dyslipidemia
- Former smoker, about 1 pack a day for 20 years, quit 2015
- No diabetes reported
Medications
- Ramipril 10 mg daily
- Atorvastatin 20 mg daily
- ASA 81 mg daily. No other blood thinners reported.
- Allergies: none reported
Prior tests and procedures
ECG at his family physician's office in September 2026. Patient reports it was "normal". No prior stress test, echocardiogram or angiogram.
Family history
Father: MI at age 61.
Flagged for review
Contains only what the patient reported. For clinician review.