CHART NOTE - Internal Medicine - Admission Day 1

Patient is a 58-year-old male admitted for evaluation of chest pain that began two days ago while climbing stairs. He denies any radiation to the jaw or arm. History of hypertension, diagnosed eight years ago, managed with amlodipine. Family history notable for father with myocardial infarction at age 61.

On examination, blood pressure 148 over 92, heart rate 88 regular, no jugular venous distention. Lungs clear to auscultation bilaterally. No peripheral edema. ECG shows nonspecific ST changes; troponin within normal limits, repeat pending. Chest x-ray shows no evidence of pneumonia or congestive failure.

Assessment and plan: Possible unstable angina. Cardiology consulted for possible stress testing tomorrow. Aspirin started. Patient counseled on smoking cessation; he reports smoking one pack per day for thirty years. Follow-up lipid panel ordered. Discharge planning to include amlodipine continuation and outpatient cardiology follow-up within one week.