HISTORY: This is a gentleman with a history of gastroesophageal reflux disease, hypertension, anxiety, hiatal hernia, and peptic ulcer. He is having four days of substernal chest heaviness and epigastric discomfort. He has no anorexia, nausea, vomiting, or weight loss. The symptoms seem fairly constant over last four days. He has been on omeprazole and now on Nexium with no improvement of symptoms. He had been on Daypro for arthritis condition, which he stopped about seven days ago and is now given a prescription for Celebrex. He is not dizzy. He is not weak. He is not sweaty. He is not short of breath.

PAST MEDICAL HISTORY: He has history of hypertension.

FAMILY HISTORY: He has no family history of coronary artery disease that he is aware of.

PHYSICAL EXAMINATION: He appears comfortable. His pulse is 72 per minute and regular. Respiratory rate is 14 and unlabored. He is in no acute distress. His skin is warm and dry. There is no pallor. Conjunctiva is pink. Sclera is white. No palpable supraclavicular or cervical adenopathy. The chest is bilaterally clear. His abdomen shows normoactive bowel sounds. Soft and nontender belly. No hepatosplenomegaly. No masses. Rectal exam was declined. Extremities are without clubbing, cyanosis, or edema. He points to his lower sternal area as an area of "heaviness." This has been there for four days with some improvement since stopping his Daypro and taking Nexium and omeprazole.

IMPRESSION: Substernal chest discomfort in a patient who is 58 years old, hypertensive with history of high blood pressure, gastroesophageal reflux disease and peptic ulcer disease.

PLAN: I spoke with the patient and wife at length. I have explained to them that though his symptoms certainly could be gastrointestinal in origin, I certainly have a graded fear that he may have some Cardiology event or pulmonary event occurring. I have suggested that he go to the emergency room. The patient flatly refuses to go to emergency room. I have explained that there is a possibility of pulmonary embolism, heart attack or other significant life-threatening event, he still refuses to go to emergency room. He agrees to be seen by the internist today but the doctor has left for the day. I have explained to the wife that I would like covering internist to call me. I have left messages evidently with both physicians at the moment. I have explained to him that should he chose he should simply go to emergency room or simply call 911. The patient again refuses emergency room or ambulance service. The patient is given a referral also for Cardiology consultation. The patient has upper endoscopy scheduled with me in two weeks but this is pending cardiology evaluation.