Name: Mr. H

Sex: Male

Address: Harlem, NY

Date of Birth: 3/05/1969, 52 years old

Date & Time: 6/21/21, 11:30 AM

Location: Metropolitan Hospital ED, East Harlem, NY

Religion: Christian

Marital Status: Married

Race: Hispanic

Source of Information: Self

Reliability: Reliable

Mode of Transport: RRT called on floor of hospital 

Chief Complaint: “I have chest pain” x this morning

History of Present Illness:

52 y/o obese male with PMH anxiety and panic attacks presents to Metropolitan hospital ED ℅ chest pain x this morning. Pt states he has been feeling chest pressure for the past week, but woke up this morning with a dull, non-radiating, centrally located midsternal chest pain. States the pain is constant, not worsening nor improving, 6/10 severity, aggravated by laying down and alleviated by sitting up. He also admits to palpitations, diaphoresis, nausea, and abdominal pain. Pt states he has been feeling CP on and off over the past few months, but prior to that, never felt this pain before. Pt denies taking any medications for the pain. States he has been feeling very stressed and anxious over the past few weeks since he has been given more responsibilities at work that he feels he cannot handle. Pt admits to drinking 5-7 alcoholic drinks on Friday and on Saturday, and felt depressed because of it on Saturday. Pt had bilateral phlebectomy for varicose veins 1 month ago. Denies SOB, dizziness, vomiting, diarrhea, heartburn, fever, cough, LOC, leg swelling, history of DVT/PE, or recent cold/ flu symptoms. 

Past Medical History:

Present medical illnesses – anxiety, panic attacks

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History- Bilateral phlebectomy, for varicose veins, 1 month ago

Home Medications:

1. Clonazepam, PO, .25 mg tablet BID, for anxiety/ panic disorder

Allergies:

No known food, drug, or environmental allergies.

Family History:

Father- 81, has diabetes

Mother- 82, has cervical cancer

Daughter- 23- Alive and Well

Maternal/ Paternal Grandparents- Deceased at unknown ages for unknown reasons

Social History:

Mr. H is a 52 year old married male, living with his wife in a 3rd floor apartment. He works for patient financial services at Metropolitan Hospital. 

Habits – Patient drinks one cup of coffee every morning. Admits to drinking alcohol occasionally, as well as having a significant amount this weekend. Denies smoking, use of e-cigarettes or any illicit drug use. 

Travel- Denies any recent travel.

Sleep – Admits that he has not been sleeping well for the past week, since he has been feeling very anxious.

Exercise – States that he walks for about 15 minutes every day. 

Diet- Patients admits that he does not have a balanced diet. Eats a bagel in the morning, a sandwich for lunch, and rice and fried meat for dinner. His diet consists of minimal fruits and vegetables.

Sexual History: Monogamous, has single female partner. Currently sexually active. Denies history of sexually transmitted infections.

Review of Systems:

General – Admits to fatigue and diaphoresis. Denies loss of appetite, recent weight loss or gain, generalized weakness, fever, chills, or night sweats..

Head – Admits to headache. Denies dizziness, vertigo or head trauma, unconsciousness, head fracture or coma.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies sore throat, sore tongue, bleeding gums, mouth ulcers, voice changes. 

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

Pulmonary system – Denies dyspnea, DOE, shortness of breath, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system –Admits to chest pain and palpitations. Denies chest pain, palpitations, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system –Admits to nausea and abdominal pain. Denies changes in appetite, intolerance to foods, vomiting, diarrhea, constipation, dysphagia, pyrosis, flatulence, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool. 

Genitourinary system –Admits to urinary urgency, frequency, nocturia, and polyuria. Deniesoliguria, incontinence, dysuria, hesitancy, dribbling, or flank pain.

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

Nervous System–Denies seizures, loss of consciousness, ataxia, loss of strength, change in sensation/tingling/ numbness, change in cognition / mental status / memory, or asymmetric weakness.

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

Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

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

Psychiatric –Admits to increased stress and anxiety, as well as depression and feelings of hopelessness after drinking a lot of alcohol this weekend. Sees a therapist and psychiatrist regularly for anxiety and panic disorder. Denies suicidal ideation at this time.

 Physical Exam

General: 52 year old male, alert and oriented to person, place and time. Patient is of average build and has good posture, is well dressed, well groomed, and has good hygiene. Patient appears anxious. 

Vital Signs: BP: 130/56, supine                       

R: 18 breaths/min unlabored     

P:96 beats/min, regular       

T: 98.2 Degrees F (oral)                      

O2 Sat: 97% on Room air

Height: 69 inches                Weight: 209 pounds            BMI:30.9- obese

Skin- Warm and dry, smooth, poor turgor, nonicteric. No lesions, masses, scars, tattoos, thicknesses or opacities.

Nails- Normal color size and shape of the nails. No spooning, clubbing, fissures, paronychia noted. Capillary refill <2 seconds throughout hands and toes.

Head-Atraumatic, normocephalic. Nontender to palpation on the frontal, temporal, occipital, and parietal areas. No deformities or specific faces noted.

Heart-Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. Carotid pulses are 2+ bilaterally without bruits.

Thorax & Lungs 

Chest – Symmetrical, no deformities, no evidence of trauma. Respirations are unlabored, no paradoxical 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.

Abdomen-Abdomen flat and symmetric with no striae, scars or pulsations noted. Abdomen soft, not distended, but diffusely tender to palpation across all 4 quadrants, no guarding or rebound noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Mental Status Exam- patient is alert, attentive, and oriented. Speech and language are clear and fluent with good word comprehension. Appears to be very anxious, has insight and judgment into his medical problems. Memory and cognitive ability intact, gave accurate information upon assessment of history.

Peripheral Vascular Exam- Skin normal in color and warm to touch upper and lower extremities bilaterally.  No calf tenderness bilaterally, equal in circumference, no edema. No palpable cords or varicose veins bilaterally. No cyanosis, clubbing / edema noted bilaterally.

Differential Diagnoses

1. Acute Coronary Syndrome- pt has sharp midsternal chest pain, as well as fatigue, palpitations, diaphoresis and nausea. He also admitted to feeling chest pressure which could be a sign of ACS. 
2. Arrhythmia/ “Holiday Heart Syndrome” – patient has chest pain, pressure and palpitations, as well as fatigue, after drinking heavily over the weekend.
3. Pulmonary Embolism-Pt has chest pain, palpitations, and diaphoresis. He also has recent history of phlebectomy which could have risk of PE. However, no SOB, no leg swelling/ sign of DVT
4. Anxiety/ Panic Attack- Pt has history of anxiety/ panic disorder and admits to having an increase in stress and anxiety recently due to increased work responsibilities. All of his symptoms- chest pain, palpitations, diaphoresis, fatigue, nausea, abdominal pain could be due to anxiety
5. Pericarditis- has chest pain and palpitations, as well as general fatigue, pain is better when sitting up and worse when laying down, consistent with pericarditis. However, no recent history of viral or bacterial infection, no other risk factors
6. Pancreatitis- important to rule out since patient has midsternal chest pain, which could be radiating from his abdomen, as well as nausea and abdominal pain. Not highly likely since no fever or other signs of infection.

Assessment

52 y/o obese male with PMH anxiety and panic attacks presents to Metropolitan hospital ED ℅ chest pain x this morning. He also admits to fatigue, palpitations, diaphoresis, nausea, and abdominal pain. PE was significant only for mild diffuse abdominal tenderness. 

Plan

1. Chest pain, palpitations, fatigue, diaphoresis- obtain CBC, CMP, EKG to r/o ACS/Arrhythmia/ pericarditis, troponins to r/o ACS, CXR to r/o pericarditis/ PE, d-dimer to r/o PE, consider Cardiac Echo to look for pericardial effusion/ heart structure
2. Nausea, abdominal pain-lipase to r/o pancreatitis
3. Feelings of stress and anxiety- patient already sees mental health professional and psychiatrist and is on medication for panic disorder. However, expresses stress specifically over job responsibilities. Listen and empathize with patient, discuss options regarding speaking to boss about difficulties with job responsibilities, and refer to on-site mental health clinic. Ensure that patient is stable and will not self harm.  
4. Obesity- discuss with patient the harms associated with obesity, and importance of healthy eating habits and getting more exercise in order to lose weight and sta healthy. 
5. Frequency, urgency, polyuria, nocturia – though not his primary complaint, consider rectal exam, PSA test, or referral to urologist to further evaluate urinary complaints.