HISTORY OF PRESENT ILLNESS
Mr. Bass is a 42-year-old white male who came in with chest
pain. He states occurred approximately 5
p.m. yesterday. He had associated
shortness of breath. He described the
chest discomfort as a pressure-like sensation in his left chest radiating to
his left upper arm. It has been
intermittent with sharp pain and it has associated shortness of breath and
diaphoresis. He was here a couple of
weeks ago for shortness of breath after an exertional episode. The patient is a policeman and he was chasing
someone. He could not get his breath
back. He was evaluated and had
respiratory treatments and states he felt better. He has no documented history of coronary
disease. He has had foreign travel
within the last 6 months.
MEDICATIONS
Include:
1. Zestril
20 a day.
2. Protonix
40 a day.
3. Advair
inhaler.
4. Celexa 40
a day.
ALLERGIES
None known.
SOCIAL HISTORY
Patient does not drink or smoke. He does not take drugs. He is married and lives locally, works with
the police department.
FAMILY HISTORY
Mother had coronary disease and bypass at age 48.
REVIEW OF SYSTEMS
GENERAL: No fever,
chills, weight loss, syncope.Positive for episodes of dizziness. EYES: No vision changes. ENT: No hearing changes, dysphasia. CARDIOVASCULAR: Positive for chest pain and shortness of
breath as described. No palpitations,
PND, pedal edema. He does have
diaphoresis. RESPIRATORY: No sputum, cough, hemoptysis, wheezing. He did have an episode of shortness of breath
a couple of weeks ago as well. GU: No
nocturia, polyuria, frequency. GI: No nausea, vomiting, diarrhea, hematochezia,
hematemesis. MUSCULOSKELETAL: No
arthralgias, myalgias. SKIN: No cyanosis, rash, ulceration. PSYCHIATRIC: No depression, anxiety. NEURO: No weakness, TIA, seizures,
headaches. ENDO: No thyroid disease. IMMUNOLOGIC: No infectious disease, night
sweats. HEMATOLOGIC: No bruising or bleeding. All other review of systems remained
negative.
PHYSICAL EXAMINATION
VITAL SIGNS: Blood
pressure 132/84, heart rate 86, respirations 20, weight 230. HEAD, EARS, EYES, NOSE, AND THROAT: Pupils equal, round, reactive to light and
accommodation. Mucous membranes pink and
moist. NECK: Supple without masses. Jugular venous pressure appears normal. Carotid upstroke is brisk without bruit. HEART:
Rhythm is regular. S1, S2 are
normal. There are no murmurs, gallops,
rubs noted. LUNGS: Clear to auscultation bilaterally. No wheezing, rhonchi, or rales. ABDOMEN: Soft, nontender. Bowel sounds present in all quadrants. EXTREMITIES:
Show no clubbing, cyanosis, edema.
Peripheral pulses intact. NEURO: Intact.
LABORATORY DATA
CT of the chest was normal.
D-dimer 134; CK 124, 94; MB 1.3, 1.1, cTnI 0.04, 0.02. Sodium 138, potassium 3.7, chloride 106,
bicarb 28, BUN and creatinine 17 and 1.4, glucose 99. WBC 6.9, H and H 16.1 and 46.5, platelets
171.
EKG: Sinus rhythm with ventricular rate 96, no other acute
ST and T-wave changes noted.
IMPRESSION
1. Chest
pain. Enzymes negative for 2 sets. D-dimer negative. Chest CT normal.
2. Hypertension.
3. Strong
family history of coronary disease.
4. Foreign
travel within 6 months.
RECOMMENDATIONS AND DISCUSSION
Cardiolite GXT in the a.m.Get serial enzymes and lipid
profile.
Dr. Buckley, who saw, evaluated, and formulated the plan on
this patient.
No comments:
Post a Comment