Identifying Data:
Full Name: Mr. VE
Address: Queens, NY
Date of Birth: January 10th, 1954
Date & Time: November 30th, 2020
Location: NYPQ
Religion: Catholic
Source of Information: Self
Source of Referral: Self
Mode of Transport: Self
Chief Complaint: “Chest pain and dizziness” x today
HPI:
68-year-old male with PMHx of dialysis (ESRD), HTN/HLD, CAD, gout, diverticulitis, and umbilical hernia is here today due to complains of chest pain. Pt was already admitted to medicine for diverticulitis but when he went to get his dialysis, he started to experience sudden left sided chest pain with no radiation anywhere else. He describes the pain as sharp and tightness around his chest area. Pain is constant and he gives it a 5/10 on the severity scale. Patient also states chest pain is associated with dizziness. He feels like the room is spinning but no signs of vomiting and has not lost his equilibrium and has not fallen. He has experienced chest pains before but the dizziness is something new. Tylenol was given for the pain but did not help. Patient denies diarrhea, constipation, shortness of breath, back pain, abdominal pain, cough, fever, chills, dysuria, and leg swelling.
DDX:
1) Acute Coronary Syndrome
2) Arrhythmias (A.fib, AV-block, SVT)
3) Pulmonary Embolism
4) GERD
5) Musculoskeletal chest pain
Past Medical History:
Past/ Present illnesses – Dialysis for ESRD x 2 years, HTN/HLD x 6 years, CAD x 1 year, gout x 2 years, diverticulitis x 2 years, umbilical hernia x 10 years.
Hospitalizations: Was hospitalized for ESRD due to electrolyte imbalance in 2019.
Immunizations- Up to date.
Screening tests and results- Colonoscopy done 4 years ago, benign.
Past Surgical History:
Percutaneous peritoneal dialysis catheter placement done in 2018, no complications.
Medications:
Cardio: Amlodipine PO, 100mg daily
Carvedilol PO, 12.5 mg every 12 hrs.
Heme: Aspirin PO, 81mg daily
Endo: Atorvastatin PO, 40 mg bedtime daily.
GI: Docusate-Senna PO 2 tablets.
Pantoprazole 40 mg PO.
Musculoskeletal: Colchicine PO, 0.6 mg, twice a day
Allergies:
Denies drug, environmental or food allergies.
Family History:
Denies family history of cardiovascular diseases, colon cancer, strokes.
Social History:
Mr. VE denies current smoking and alcohol use. However, he has a history of alcohol abuse and stopped when diagnosed with ESRD. He denies illicit drug use.
Currently lives with his wife in Queens. Not on a specific diet and does not exercise.
Travel- Has not recently travel anywhere
Sexual hx- Sexually not active. No past history of STD’s, HIV, or any other sexually transmitted diseases.
Review of Systems:
General: Reports some recent weight loss due to ongoing medical conditions he has and has some loss of appetite. Denies fatigue, fever, or night sweats.
Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, or changes in hair distribution.
Head – Reports dizziness that started today associated with the chest pain. Denies head trauma, or headaches.
Eyes – Denies lacrimation, pruritis, visual disturbances, or photophobia. Last eye exam 2015 – does not know his visual acuity, normal pressure.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat –Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, jaw soreness. Last dental exam 2019.
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 – Sharp, constant pain and tightness on his left chest area that started 2 hrs while he was in dialysis. Chest pain also associated with dizziness. Denies palpitations, edema/swelling of ankles/feet, known heart murmur.
Gastrointestinal system – Reports some recent weight loss and poor appetite. Has regular bowel movements daily. Denies, abdominal pain, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
Genitourinary system – Denies nocturia, urinary frequency or urgency, oliguria, polyuria, dysuria, incontinence.
Nervous – Reports dizziness that started with the chest pain. Denies seizures, headaches, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status.
Musculoskeletal system –Denies muscle/joint pain, deformity or swelling, redness or arthritis.
Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Denies mood changes, dementia, depression. Denies sadness, OCD.
Physical exam:
General: Pt is alert and oriented x3, neatly groomed, appears of stated age and in slight apparent distress.
Vital Signs: BP: 122/83
R: 19/min unlabored P: 103, regular
T: 98.7 degrees F (oral) O2 Sat: 90% Room air
Height 5’10’’ Weight 135 lbs. BMI: 19.4 (normal)
Skin: warm to the touch & moist, good turgor. Nonicteric, no lesions noted, no scars, no tattoos.
Head: Head is normocephalic, atraumatic.
Ears: Symmetrical and normal size. EOMs intact, PERRL. No conjunctival injection. No scleral icterus.
Nose – Symmetrical / no obvious masses / lesions / deformities / trauma / discharge. Nasal mucosa pink & appears dehydrated.
Oropharynx –no evidence of injection; exudate; masses; lesions; foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pinkish, no edema, lesions.
Neck – Trachea midline. No masses; lesions; scars; pulsations noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally.
Thyroid –Non-tender; no palpable masses; no bruits noted.
Chest/Lungs:
Symmetrical without deformity or signs of trauma. Respiration unlabored and without use of accessory muscles. Non-tender to palpation. Clear to auscultation bilaterally with no adventitious lung sounds.
Heart: Slightly Tachycardic but regular rhythm; S1 and S2 are normal. There is no re-producible chest pain when palpating There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.
Abdomen: Abdomen was flat / symmetrical, no caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. No evidence of organomegaly. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.
Peripheral Vascular:
The extremities are normal in color, size, and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No ulcerations noted.
Upper & Lower Extremities:
Slight erythema and tenderness in his right big toe. No ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. No crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Motor Systems no evidence of atrophy, fasciculations or abnormal movements
normal muscle bulk, contour and tone
Muscle Strength: Right Left
upper extremities 4/5 4/5
lower extremities 5/5 5/5
rapid alternating movements and point to point movements intact, no asterixis
gait normal, Romberg negative, slight pronator drift
Sensory Systems dull, thermal, and light touch sensation intact upper and lower extremities bilaterally, vibratory sensation intact over great toe bilaterally
proprioception, stereognosis, graphesthesia, two-point discrimination, point localization and extinction intact
Reflexes
Biceps Brach. Triceps Abd Knee Ankle Plantar Response
RT 2+ 2+ 2+ 2+ 2+ 2+ Down-going
LT 2+ 2+ 2+ 2+ 2+ 2+ Down-going
Side note: Lung and heart exam was done at the moment; however, the rest of the physical exam was done after PCI due to this being an emergency and I had no time to do a full physical exam at the moment of his acute chest pain.
Orders & Labs:
-WBC: 7.56 (4.80-10.80)
-HGB: 12.5 (11.7-15.3)
-HCT: 38.11 (35.0- 45.0)
-MCV: 89.3 (78-100.0)
-PLT: 345 (150-400)
-Lactate: 0.6
–Cr: 4.15
–Troponin #1: 0.2
–Troponin #2: 0.6
–Troponin #3: 1.4
EKG: ST-elevation V1-V4.
Assessment:
Mr. VE is a 68-year-old male with PMHx of dialysis (ESRD), HTN/HLD, CAD, gout, diverticulitis, and umbilical hernia who started to complain today of chest pain and dizziness after going for his dialysis. He is currently tachycardic and O2 saturation at 90% on room air with a normal physical exam. His troponin levels have been trending upwards and there is ST elevation leads V1-V4.
Plan:
1) Pt is having an anterior myocardial infraction most likely due to dialysis.
2) Call cath lab to get ready for PCI.
3) While getting pt ready to take him for PCI, have him chew aspirin, and administration of nitroglycerin (0.4mg) and start him on nasal canula since his O2 saturation on room air is at 90%.
4) Also start him on beta blockers since he is tachycardic (103 beats per mins).
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