History:

Date & time: 09/13/22 10:00 am

Full Name: AA

DOB: 09/23/1961

Address: Jamaica, NY

Age: 60 y/o

Sex: Male

Race: Hispanic

Religion: Christian

Source: Pt. himself

Transportation: Self 

Reliability: Reliable

Location: Flushing, NY

Chief Complaint: “My chest hurts” x 1 days

History of Present Illness:

     60 y/o male with PMH of HTN, HLD, DM2, CAD with triple vessel disease s/p 3 stents in 2015 presented to the ED 4 days ago complaining of chest pain with exertion at home. Pt. states that the pain started right before he came in and had a sudden onset that occurred when he was doing a cardio workout  at home. He states the pain was localized to the left side was consistent in duration and characterized it as a heavy feeling in his chest. He reports that nothing alleviated or aggravated his symptoms and that it did not radiate anywhere else and describes the severity as a 3/10. Pt. denied any accompanying symptoms such as SOB, palpitations, edema, syncope, or cough. After admission pt received s/p Cath on 9/12 with 2 stents placed at LAD with no complications. Today pt. is being evaluated for discharge. Pt. states his chest pain has fully resolved and does not report any accompanying SOB, palpitations, edema, cough, fever, chills, fatigue. 

Past Medical History:

• DM2 x 20 years controlled medically.
• HTN x 20 years controlled medically.
• HLD x 20 years controlled medically.
• CAD x 7 years controlled medically.
• Immunizations up to date; flu vaccine yearly (unknown date); Covid vaccines and booster up to date (unknown dates).

Past Surgical History:

• Cardiac cath with 3 stents placed in 2015, due to CAD with triple vessel disease, no complications.
• TURP 20 years ago, due to BPH, no complications
• Pt. denies past blood transfusions.

Medications:

• Metformin 500 mg PO QD, for DM2, last dose 10/10/22.
  • Insulin Lispro, 1-5 units, Subq TID WC, to substitute metformin to treat DM2 while admitted
• Plavix 75 mg, PO QD, for CAD, last dose this am.
• ASA 81 mg PO QD, for CAD, last dose this am
• lisinopril 20 mg, PO QD, for HTN, last dose this am
• Denies use of herbal supplements.

Allergies:

• NKDA
• Denies seasonal, food, and animal allergies.

Family History:

• Mother – age 83 alive and well
• Father – alive age 85 h/o HTN and DM2
• Maternal/paternal grandparents – deceased at unknown age & unknown reasons
• Daughter – age 30 alive and well
• Son – age 35 alive and well

Social History:

• Habits- Pt. denies h/o of smoking or tobacco use along with illicit drug use. Pt. also denies alcohol and caffeine use. 
• Travel- Pt. denies any recent travel.
• Marital history- Married to wife for over 30 years.
• Occupational history- Factory worker.
• Home situation- Lives with wife.
• Diet- Pt. states that his diet consists mainly of vegetables, protein, and rice.
• Exercise- Pt. states he exercises for at least an hour every day.
• Sexual Hx- Heterosexual,e. Denies h/o sexually transmitted diseases.
• Safety measures– Admits to seat belt use.

Review of Systems:

General – Denies fever, night sweats, weight loss or gain, generalized fatigue, chills, changes in appetite.

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

Head – Denies headaches, vertigo, or head trauma, dizziness

Eyes – Denies glasses or contact usage, Last eye exam 2021 visual acuity unknown. Denies glasses or contact usage, visual disturbances, photophobia, lacrimation, or pruritus.

Ears – Denies deafness, pain, discharge, tinnitus.

Nose/sinuses –Denies discharge obstruction, or epistaxis.

Mouth/throat – Last dental exam February 2022. Denies sore throat, bleeding gums, sore tongue, mouth ulcers, or voice changes.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast – Denies lumps, nipple discharge, or pain.

Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system – Denies palpitations, chest pain, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

Gastrointestinal system – Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructation, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

Genitourinary system – Denies urinary frequency or urgency, nocturia, oliguria, polyuria, dysuria, incontinence, awakening at night to urinate or flank pain.

Nervous – Denies migraines, seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, changes in cognition / mental status / memory, or weakness.

Musculoskeletal system –Denies muscle/joint pain, deformity or swelling, or redness.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.

Hematological system –Denies anemia, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.

Physical:

General: Medium sized male, neatly groomed, looks older than her stated age of 60 years

Vital Signs: BP:                             R                                                       L

                  Seated                        124/73                                               126/72

                  R: 15/min, unlabored                                               P: 79 beats/min, regular

                  T: 98.6 degrees F (oral)                                         O2 Sat: 93% Room air

                  Height: 69-inches              Weight: 175 lbs                  BMI: 25.8

Skin: warm & moist, good turgor. Nonicteric, no lesions noted, no scars.

Hair: average quantity and distribution. 

Nails: no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non-tender to palpation throughout

Nose: Symmetrical / no masses / lesions / deformities / trauma / discharge. Nares patent bilaterally / Nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No foreign bodies.

Sinuses: Non tender to palpation and percussion over bilateral frontal, ethmoid, and maxillary sinuses.

Ears: Symmetrical and appropriate in size. No lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM pearly grey / intact with light reflex in good position AU. Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC>BC AU.

Lips –   Pink, moist; no cyanosis or lesions.

Mucosa – Pink; well hydrated. No masses: lesions noted. No leukoplakia.

Palate – Pink; well hydrated. Palate intact with no lesions; masses; scars. 

Teeth – Good dentition / no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue – Pink; well papillated; no masses, lesions, or deviation.

Oropharynx – Well hydrated; no injection, exudates, masses, lesions, or foreign bodies.

Tonsils grade 1 present with no injection or exudates. Uvula pink, no edema or lesions.

Neck – Trachea midline. No masses; lesions; scars; pulsations noted.   Supple; non-tender to palpation. FROM; no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally, no cervical adenopathy noted.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink. Visual acuity uncorrected – 20/20 OS, 20/20 OD, 20/20 OU
Visual fields full OU. PERRLA, EOMs intact with no nystagmus 
Fundoscopy – Red reflex intact OU. Cup to disk ratio< 0.5 OU. No AV nicking, hemorrhages, exudates, or neovascularization OU.

Chest: Symmetrical, no deformities, no trauma. Respirations unlabored / no paradoxical respirations or use of accessory muscles noted. Lat to AP diameter 2:1. non-tender to palpation throughout.

Lungs: Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.

Heart: JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5^th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.

Breasts: Symmetric, no dimpling, no masses to palpation, nipples symmetric without discharge or lesions.  No axillary nodes palpable

Abdomen: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation and tympanic throughout, no guarding or rebound noted. Tympanic throughout, no hepatosplenomegaly to palpation, no CVA tenderness appreciated.

Male Genetalia and Hernias: Circumcised male. No penile discharge or lesions. No scrotal swelling or discoloration. Testes Descended bilaterally, smooth and without masses. Epididymis nontender. No inguinal or femoral hernias noted.

Anus, Rectum, and Prostate: No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and non-tender with palpable median sulcus Stool brown.

Differential diagnosis:

1. MI- pt. has a risk factor (HTN, DM2, HLD, CAD) and is complaining chest pain. Would have ordered stat EKG. Would have ordered CBC, CMP/BMP, troponin, CPK, CXR. Would treat it with asa, morphine, nitro, and give oxygen.
2. Aortic dissection- pt. has a risk factor ( HTN, DM2, HLD, CAD) and is complaining of chest pain. Will order stat CT angio with contrast, would control pain with morphine, would order CMP, CBC, type and screen, troponin and will closely monitor pt. vitals. Would treat with control of BP to keep within a range of 185-175/98-87 or lower and refer to cardiothoracic surgery for repair of dissection.
3. CHF- pt. has a risk factor ( HTN, DM2, HLD, CAD) and is complaining of chest pain that occurred with minimal exercise. Would order EKG, CXR, echo. Would have ordered CBC, CMP/BMP, troponin, CPK, BNP. Would treat with supplemental O2 and pressors with inotropic meds if hypotensive or lasix and nitro if hypertensive.
4. Angina-  pt. has a risk factor ( HTN, DM2, HLD, CAD) and is complaining of chest pain. Pain occurred after minimal physical exertion and did not resolve with rest. Would have ordered stat EKG. Would order CBC, CMP/BMP, troponin, CPK, CXR, to verify that cardiac markers are not elevated. would treat it with asa, morphine, nitro, and give oxygen.
5. Pericarditis- pt. has a risk factor ( HTN, DM2, HLD, CAD) and is complaining of chest pain. Would have ordered EKG to check for diffuse ST elevations. I would also order CBC, BNP, ESR, CRP, and Trop. To treat I would treat the underlying cause and have the patient take NSAIDs.