History

Identifying Data:

Full Name: Mr. S. R

Address: Queens, NY

Date of Birth: Jan 09, 1955

Date & Time: Mar. 12, 2019 / 8:10 a.m.

Location: ED, NYHQ, Flushing, NY

Religion: Atheists

Source of information: Self

Reliability: Reliable

Source of Referral: None

Mode of Transport: Bus

CC: “I feel pressure on my chest” X 5 days

HPI:

Reliable 64 y/o Africa American male, with PMH of uncontrolled HTN and pervious smoker presented to ER this morning with chief complain of chest tightness for 5 days. Pt states the tightness feeling was sudden start when he lay down at midnight 5 days ago. It is intermittent and irregular, occurring every time when he lay down and would last approximately 5 to 10 minutes. The tightness always associated with pain. He describes the pain as heaviness in character and located on the mid chest without any radiation. He rates the pain as 3/10 as its worst. The tightness and pain are alleviated after sit up and rested in a cool area. He also took Aspirin for the past 2 days to relief the pressure and pain gradually, and is not worsened by anything. The symptoms are also noticed once when he got off the bus and walked on the street yesterday night. Pt also c/o SOB, dry cough and sleeping problem for the past 4 days. He denies vomiting, diarrhea, headache, dizziness, palpitation, sweating, fever, lightheadedness, PND, orthopnea, loss of consciousness, peripheral edema. He has been off of his HTN medication for the past 2 years, because he believes the medication does not control his BP well.

Past Medical History:

Present illnesses –HTN x 8 years

Past medical illness – Left shoulder dislocation (2004)

Hospitalizations – Arthroscopic surgery, 2004, NYHQ (unable to recall surgeon name)

Childhood illnesses – denies any illness

Immunization – up to date; last flu vaccine yearly.

Screening test and results – denies recent test

Past Surgical History:

Arthroscopic surgery, 2004, due to shoulder dislocation, no complication

Denies past injuries or transfusions.

Medications:

Aspirin (325 mg), 1 tab p.o. daily for chest pain, last dose yesterday night

Allergies:

Seasonal allergies, itchy, watery eyes, and sneezing

NKDA, or food allergies

Family history:

Mother – Deceased at age 71, lung cancer

Father – Deceased at age 68, emphysema

Sister – Deceased at age 60s, suicide

Sister – 55, alive and well

Daughter – 46, alive and well

Daughter – 44, alive and well

Son – 33, alive and well

Maternal/paternal grandparents – Deceased at unknown age & unknown reasons

Social History:

Mr. S. R. is a married male, living with his wife. He is a MTA worker and currently works at night shift.

Habits – He is a previous every day smoker, half pack of cigarettes per day and 10 pack-year, and quit on 2018. He drinks 1 cup of caffeine per day. Denies drinking alcohol/beer, or illicit drug use.

Travel – He denies traveling recently.

Diet – he has a large amount of diet with fried food, beef, and chicken; less vege and fruit.

Exercise – he walks about 2 hour per week in her community neighborhood. He does not sleep well due to chest tightness and SOB for the past 4 days and average3 hours each day.

Safety measures – admit to wearing a seat belt.

Review of systems:

General – loss 7 pounds within recent 2 months. Denies loss of appetite, generalized, weakness/fatigue, fever or chills, or night sweats.

Skin, hair, nails – denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rahes, pruritus or changes in hair distribution.

Head – denies headaches, vertigo, head trauma, unconsciousness, coma, or fracture.

Eyes – state he has for both eyes. Denies visual disturbance, like blurring, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia, pruritus. Denies recent eye exam, or use of glasses.

Ears – denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses – denies discharge, epistaxis, or obstruction.

Mouth and throat – denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Denies recent dental exam.

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

Breast – denies lumps, nipple discharge, or pain. Last mammogram 2015, negative.

Pulmonary system – states SOB and dry cough. Denise wheezing, dyspnea on exertion, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dysnea.

Cardiovascular system – history of HTN, states chest pressure and pain. Denies edema/swelling of ankles or feet, syncope, or known heart murmur.

Gastrointestinal system – regular bowel movements daily. Denies nausea, loss appetites, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.

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

Sexual Hx – states he is currently sexually active with his wife. Denies STI or contraception.

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

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

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

Hematologic system – denies anemia, easy bruising or bleeding , lymph node enlargement, blood transfusions, or history of DVT/PE

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

Psychiatric – Denies depression, sadness, anxiety, obsessive, or any experience of seen mental health professional.

Physical

Vital Signs:

BP: L 140/88, R 145/90, supine

RR: 20/min unlabored

P: 110, Tachycardia

T: 96.7 degree F, oral

O2 Sat: 99% room air

Ht: 69 inches

Wt: 150 lbs.

BMI: 22.2 normal

General: Patient is a 64 y/o male, A& O x 3. Well developed and good posture. Well dressed, groomed and nourihed. No apparent distress.

Skin/Nail/Head/Hair:

Skin – warm & moist, good turgor. No increase or loss in pigmentation, nonicteric, no thick, opaque, no scar, tattoos, no rahes or suspicious lesion

Nail – no clubbing.

Hair – average quantity and soft of hair, evenly distribution, no signs of lice, nits, no seborrhea. Nails: no clubbing, capillary refill < 2 seconds throughout.

Head – eyes and ears aligned, normocephalic, atraumatic, non tender to palpation throughout, no trauma, no specific facies.

Eye: symmetrical OU, no evidence of strabismus, exophthalmos or ptosis. Sclera white, conjunctiva and cornea clear. Visual acuity (uncorrected – 20/20 OS, 20/20 OD, 20/20 OU). Visual fields full OU. PERRLA , EOMs full with no nystagmus. Fundoscopy -Red reflex intact OU.   Cup:Disk < 0.5 OU, no evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.

Ears: Symmetrical and normal size.  No evidence of lesions, masses, trauma on external ears.  No discharge, foreign bodies in external auditory canals AU. TM’s pearly white, intact with light reflex in normal position AU. Auditory acuity intact to whispered voice AU.  Weber midline, Rinne reveals AC>BC AU.

Nose/Sinues:

Nose – Symmetrical, no obvious masses, lesions, deformities, trauma, discharge. Nares patent bilaterally. Nasal mucosa pink and well hydrated. No discharge noted on anterior rhinoscopy.  Septum midline without lesions, deformities, injection, perforation. No evidence of foreign bodies.

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

Mouth/Throat:

Lips -Pink, moist. no evidence of cyanosis or lesions. Non-tender to palpation.

Mucosa – Pink and well hydrated. No masses, lesions noted. No evidence of leukoplakia. Non-tender to palpation.

Palate – Pink and well hydrated. No lesions, masses, scars. Non-tender to palpation.

Teeth – Good dentition. No obvious dental caries noted. Non-tender to palpation.

Gingivae – Pink and moist. No evidence of hyperplasia, masses, lesions, erythema or discharge. Non-tender to palpation.

Tongue – Pink and well papillated. No masses, lesions or deviation noted. Non-tender to palpation.

Oropharynx – Well hydrated. No evidence of injection, exudates, masses, lesions, foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pink, no edema, lesions

Neck/Thyroid:

Neck – Trachea midline. No masses, lesions, scars, pulsations noted. Supple, non-tender to

palpation. No stridor noted, no thrills. Bruits noted bilaterally, no palpable adenopathy noted.

Thyroid – Non-tender to palpation, no masses, no thyromegaly, no bruits noted.

Thorax and Lungs:

Chest – Symmetrical, no deformities, no evidence trauma.   Respirations unlabored, no paradoxic respirations or use of accessory muscles noted.  Lat to AP diameter 2:1.   Non-tender to palpation.

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout.

Cardiovascular:

Sinus tachycardia. S1 and S2 are present, a questionable S4 is heard at the apex. No S3, splitting of heart sounds, friction rubs, gallops or other extra murmurs, or apical prominence. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. No JVD, cyanosis, clubbing, or edema.

Abdomen:

Flat, symmetrical, no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.

Male Genitalia : (Pt denies examination, following is normal write up)

Uncircumcised 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.

Rectal: (Pt denies examination, following is normal write up)

No external hemorrhoids, skin tags, ulcers, sinus tracts, anal fissures, inflammation or excoriations around perirectal area. External sphincter tone intact. Rectal vault without masses or tenderness. Prostate smooth and nontender with palpable median sulcus. Stool brown and Hemoccult negative.

Assessment:

64 y/o Africa American male, with PMH of HTN and previous smoker presented to ER of chest tightness with pain and SOB for 5 days.

Problem list:

1. Chest tightness with pain
2. Tachycardia
3. Uncontrolled HTN
4. Short of breath with dry cough
5. Sleeping problem
6. Weight loss

I favor the diagnosis of Angina pectoris. The chest discomfort and heaviness pain with SOB and tachycardia are highly suggestive of angina pectoris.  As well, the diagnosis is supported by the uncontrolled HTN Hx, central chest pain, and every episode occurs when pt in a supine position. In order to ensure the diagnosis of an angina pectoris, the EKG with stress test is needed, which will show if enough blood flows into the heart as he get more active. Even no nausea or vomiting is unusual, but don’t exclude the diagnosis.

A diagnosis of pericarditis is supported by patient’s sudden onset, central chest heaviness pain, and the chest pain is typically worse when the patient is in a supine position. However, pericardits usually last hours, and may associate with URI, fever, as well as, the sign of unequal blood pressure in opposing arms, or a friction rub. For additional information, an EKG should be done, CBC to check leukocytes, which is elevated in pericarditis.

Acute pulmonary embolism is supported by a tachycardia, chest pain, SOB with cough, as well as the smoking Hx. However, lack the symptom of hypoxia, rales to auscultation, lower limbs pain or swelling. Blood test, chest X-ray and ultrasound can be used to diagnostic it.

The symptom support pneumonia due to cough and SOB. However, pt present a dry cough rather than a productive cough, as well, lack the symptom of fever, rhonchi, decreased breath sounds make this less likely.

A chest pain and SOB could also be explained by Dissection of the thoracic aorta, however, the pain is more severs and commonly felt in the back; it is sudden in onset, reaches maximum intensity immediately, and may be associated with changes in pulses. So all above make this less likely. To diagnose a dissection of the thoracic aorta, a chest x-ray may be performed.

Plan:

1. Carefully monitor the patient for any increased chest pain that might be indicative of impending myocardial infarction.
2. Continues platelet inhibitors, such as aspirin to decrease the risk of myocardial infarction; start nitrates to decrease the risk of occlusion and to treat his symptoms of pain.
3. Start calcium channel blocker therapy, and monitor blood pressure.
4. Schedule a EKG, Stress test and blood test:
   1. EKG: if the electrical activity is normal or slow, fast or irregular; also find out if parts of the heart are too large or are overworked.
   2. Stress test: to assess coronary artery disease and determine a safe level of exercise.
   3. X-ray:
   4. Blood test: test cardiac enzymes (troponin and creatine kinase), CRP, fibrinogen homocysteine, lipoproteins, triglycerides, BNP and prothrombin. To confirms that a heart attack has occurred and determines extent of damage; assesses future risk for coronary artery disease.
5. Patient should have his cholesterol monitored and when discharged he should be started on an appropriate exercise DASH diet.