Emergency Department Note

54 yo male presenting with chest pain

PMH

• HTN, dyslipidemia, GERD
• Laparoscopic appendectomy (2012)
• Father had MI at age 58

Habits

• Ex-smoker (quit 5 years ago, 15 pack-year hx)
• Denies illicit drug use
• EtOH 2-3 drinks/week

Meds cf list

• perindopril (Coversyl®) 4 mg PO daily, rosuvastatin (Crestor®) 10 mg PO daily, pantoprazole (Pantoloc®) 40 mg PO daily
• Magnesium citrate 150 mg PO daily

HPI

• Retro-sternal chest pain onset 2 hours ago while resting, radiating to left shoulder, dull pressure, 6/10 severity, aggravated by deep inspiration, partially relieved by sitting forward
• Associated with mild diaphoresis
• Cardio: positive for retro-sternal chest pain, mild SOB, no orthopnea, no PND, no leg swelling, no palpitations, no syncope
• Respiratory: mild SOB, no cough, no expectoration, no URTI sx, no rhinorrhea, no hemoptysis
• no phx of dvt or PE, no calf symptoms, no recent immobilisation, no hemoptysis, no ocp or hormone use
• Abdominal: mild nausea, no vomiting, no diarrhea, no hematemesis, no melena, no BRBPR, no constipation, mild epigastric discomfort, no rectal pain, occasional EtOH, takes ibuprofen PRN for headaches, no hématurie, no dysuria, no frequency
• Constitutional symptoms: no chills, no myalgia, no arthralgia, no swollen lymph nodes, no sick contacts, no unexplained weight loss or fever
• Gyne/Gu: (no dysuria, no frequency, no hematuria), Neurological symptoms: no headache, no head trauma, (no aphasia, no ataxia, no dysarthria, no dysphagia, no dysphonia, no vision change (diplopia or loss of vision), no peripheral neuro sx (sensory or motor)), Eyes: no eye pain, redness, or vision changes, Ears, Nose, Mouth, Throat: no sore throat, nasal congestion, or ear pain

PE

• Alert, oriented x3, mild distress due to pain, diaphoretic
• BP 148/92 mmHg, HR 88 bpm, RR 18/min, T 36.8 °C, SpO2 98 % on RA
• H/N N
• Heart Ns1s2, no murmurs
• Lungs: clear GEAB
• Abdo: soft, mild epigastric tenderness, no guarding, no rebound

I/P

• Atypical chest pain, rule out ACS given cardiac risk factors and radiation, low Wells score for PE
• GERD / gastritis, history of reflux and recent NSAID use with epigastric tenderness
• ECG, serial hs-troponin I q3h, CBC, electrolytes, creatinine, CXR, acetylsalicylic acid (Aspirin®) 160 mg PO x 1 chewed, nitroglycerin (Nitrostat®) 0.4 mg SL PRN, pantoprazole (Pantoloc®) 40 mg IV x 1

Reassessment

• 14/05/2024 14:30
• Patient reports complete resolution of chest pain (0/10) following SL nitroglycerin and IV pantoprazole, nausea resolved
• Exam: NAD, skin warm and dry, HR 74 bpm, BP 128/78 mmHg, repeat heart and lung exam unchanged
• I/P: 0h and 3h hs-troponin I negative (< 5 ng/L), repeat ECG normal sinus rhythm without ischemic changes, CXR unremarkable, discharge home with outpatient stress echo requisition, stop ibuprofen, follow up with FP in 1 week, return to ED if pain recurs