Subjective:

26-year-old patient with no significant past medical history presents himself to ED from home with complaints of chest pain since yesterday. Patient states he had 2 similar episodes of chest pain, each lasting about 20 mins, start at the center of the chest and radiates to his left arm. The patient was running when the chest pain started and he describes the pain as pressure on his chest which gets better with water consumption and resting and worse while exercising. The pain is always associated with SOB and sweating and the patient rates the pain 8/10 in the severity chart. The patient states he has never experienced anything like this before. Patient denies smoking, significant past family history, HTN, cough, palpitations, irregular heartbeats, edema, wheezing, hemoptysis, cyanosis, or paroxysmal nocturnal dyspnea.

Objective:

Blood pressure: 118/65

Temperature: 98.3 orally

Pulse: 98 pulse/min, regular

Respiration: 17 breaths/min, unlabored

O2 saturation: 100%

Height= 185.4 inches        Weight= 248.8 Ib

BMI= 32.7

White blood cell count= 17.57

Hemoglobin= 14.3

Hematocrit= 43.6

Platelets count= 176

CPK= 8,000

Troponin= 0.02

Assessment:

26-year-old patient with no significant past medical history presents himself to ED from home with complaints of chest pain since yesterday.

Differential Diagnosis:

• Angina pectoris (usually chest pressure or pain on the left side of the body associated with SOB and sweating).
• Pericardial effusion (usually chest pain on the left side of the chest, associated with SOB, fever, fatigue and sometimes vomiting)
• Unlikely Myocarditis (symptoms usually include chest pain, abnormal heartbeat and SOB)
• Unlikely Pulmonary embolism (PE is associated with SOB, sweating and coughing, and in our case, Pt denies coughing).
• Unlikely Bacterial Pneumonia (SOB, chest pain but sharp feeling, sweating, loss of appetite, cough with yellow/green sputum)

Plan:

Chest pain: associated with SOB, may have cardiac ischemia. Perform EKG, echocardiogram, cardiac markers and chest x rays. Monitor chest pain, aspirin 81 mg orally once a day after lunch.  Also give Nitroglycerin when the pain becomes unbearable, 0.4 mg, orally, have the patient keep the tablet under the tongue so it can dissolve for 5 mins.

Give pt Neulasta to increase white blood cell count. 0.6 mL prefilled syringes and check his white blood cell count again.

Sweating: Monitor for excessive sweating. If excessive sweating observed, give glycopyrrolate 1.5 mg, orally, once a day after lunch.

Vaccinations: discuss risks/benefits of vaccination with patient. Follow up vaccination on discharge if patient interested.

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