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EM H&P

MEDICAL HISTORY      Date:     03/28/21                      Time: 10:50

IDENTIFICATION:          J.F.                      

Sex:         M            Race: Caucasian        Nationality: US        Age: 51           Marital status: Single

Address:       n/a                                Religion: n/a

PCD: Does not remember

Informant        Self                            Reliability             Reliable        Referral: None

CC: Chest pain since 5 am

51 y/o M w PMH of GERD and kidney stones presents to ED w a c/o 8/10 chest pain radiating to his left arm, neck, stomach and ears since 5 am. He describes the pain as sharp, stabbing, pressure-like, not relieved by leaning forward. Pain does not get worse with inspiration. Denies fever, chills, SOB, cough, pain being worse on inspiration or history of VTE. Patient states the pain woke him up from sleep. Patient has not tried to walk since it began so he is not sure if it’s exertional. Endorses nausea and diaphoresis. Denies this happening to him before. He took an antacid and 400mg Tylenol at 9 am with no relief. Of note, family history is significant of father dying from “heart disease” at the age of 40. Pt denies alcohol or drug use, denies smoking.

PMH: GERD; Kidney stones but no lithotripsy or surgery; does not know his vaccination status, last PCP visit 1.5 yrs ago

PSH: Denies

Medications: Antacid situationally

Allergies: NKDA, NKEA, NKFA

FH: See HPI

SH: J.F.is a single male living alone, denies smoking, use of alcohol, caffeine or illicit drugs. Denies being sexually active at the moment.

ROS:

General: Denies any fever, chills, night sweats, fatigue, weakness, loss of appetite

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution

Head: Denies headache, vertigo, unconsciousness, coma

Eyes: Denies photophobia ,visual disturbances, fatigue, lacrimation

 Ears: Denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Denies discharge, epistaxis, obstruction

 Mouth and throat: Denies bleeding gums, sore tongue, difficulty swallowing

Neck: Denies localized swelling/lumps, stiffness/decreased range of motion

Pulmonary system: Denies dyspnea, SOB, cough, wheezing, hemoptysis, cyanosis, orthopnea, PND

Cardiovascular system: Admits to chest pain as per HPI, denies HTN, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope, known heart murmur

Gastrointestinal system: Endorses slight nausea but no vomiting this morning, denies changes in appetite, intolerance to foods, dysphagia, pyrosis, flatulence, eructation, abdominal pain, diarrhea, jaundice, change in bowel habits, hemorrhoids, constipation, rectal bleeding, blood in stool, pain in flank

Genitourinary: Denies frequency, incontinence, dysuria, nocturia, urgency, oliguria, polyuria, hesitancy, dribbling

Musculoskeletal system: Denies Muscle/joint pain, deformity or swelling, redness

Peripheral Vascular system: denies intermittent claudication, coldness of trophic changes, varicose veins, peripheral edema, color change

Hematologic System: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE

Endocrine system: Denies generalized weakness, polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, hirsutism

Nervous system: Denies seizures, loss consciousness, sensory disturbances (numbness, paresthesia, dysesthesias, hyperesthesia), ataxia, loss of strength, change in cognition/mental status/memory, weakness (asymmetric)

Psychiatric: Denies depression/sadness (Feelings of helpless, feelings of hopelessness, lack of interest in usual activities, suicidal ideation), anxiety, obsessive/compulsive disorder

DDX:

  • STEMI/NSTEMI
  • PE
  • Dissection
  • Tamponade
  • Esophageal Rupture

General: Pt is alert & oriented x 3, uncomfortable, pale, diaphoretic and anxious

VS:

  • BP: 147/100, RA, supine
  • T: 36.8 C oral
  • HR: 75 BPM
  • O2SAT: 96% RA
  • RR: 23 breaths/min, no retractions

Physical Exam:

  • Skin: clammy, no edema/erythema, ecchymoses
  • Head: normocephalic, atraumatic, non-tender to palpation throughout
  • Eyes: symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear.  
    • PERRL,  EOMs full with no nystagmus  
    • Red reflex intact OU
  • ENMT: mucous membranes moist, pharynx w no erythema, airway patent, no stridor.
  • Neck: no tenderness or stiffness
  • Respiratory: Lungs CTABL, breath sounds equal bilaterally, no rales, rhonchi or wheezes
  • Cardiovascular: Regular S1 and S2 with no murmurs or gallops
  • GI: Abd soft, non-distended, no tenderness, no guarding, no rebound, no CVA tenderness
  • Back: No Paravertebral tenderness, no midline tenderness, no spasm
  • MSK: No deformity, no edema, no tenderness, FROM
  • Neuro: Alert. Normal speech, normal tone, normal gait. CN II – XII intact. Muscle strength 5/5 throughout. Sensation intact. Negative Romberg. Negative Pronator drift. Normal finger-nose-finger. No nystagmus.

DDX:

  • STEMI/NSTEMI – likely due to patient story and risk factors (Age, family history)
  • PE – not likely due to absence of SOB,O2SAT>95%, pain being non-pleuritic, and no history of VTE (Patient’s well’s score is 0)
  • Dissection
  • Tamponade
  • Pneumothorax
  • Pneumonia – not very likely due to absence of cough/fever.
  • Esophageal Rupture – not likely due to absence of GI Sxs

Assessment:

51 y/o M presents with history suspicious for MI. Need to r/o dissection, tamponade. Initial EKG showed 1mm ST elevations in V1 and V2 with hyperacute T waves.

Plan:

  • Activate STEMI code – STAT cardiology consult
  • IV x 2, Cardiac monitor, pulse ox, Repeat EKG, trend Troponin
  • CXR
  • Dual antiplatelet: ASA + Plavix (Clopidogrel)
  • Antithrombotic: Heparin
  • Statin
  • Pain control: Nitroglycerin SL
  • Bedside Echocardiogram to access heart wall movement and aorta

Progress note: Repeat EKG showed significant ST elevations in leads V1-V6 and AVF, Echo revealed no anterior wall movement and intact aorta. Patient was taken STAT to the Cath lab. 100% LAD occlusion was discovered, and 4 stents were placed. Patient tolerated the procedure well. Patient’s PCP was notified. Patient was set up with a PCP follow up.

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