Chest Pain

Chest Pain, ED Physician Note:

Clinical History:

?? -year-old male , known to have; Diabetes mellitus, hypertension, Dyslipidemia, obesity, and active smoker, No record of cardiac diseases or cardiac evaluation in recent years.

Chief Complaint; gradual central chest pain for 2hrs then resolved,  described as pressure (Crushing, Tearing, Pleuritic or Indigestion/Burning), 7/10 in severity, radiating to both upper arms and neck, with shortness of breath worsened by exertion and relieved by rest, no hx of palpitations, orthopnea or PND.

-He denies any fevers, cough, nausea, vomiting, abdominal pain, light-headedness, diaphoresis, numbness, or reflux symptoms. He has not had recent surgeries, hospitalizations, or traumas.

-He has never had an episode like this in the past and did not try any medication to relieve the pain. 

-No known drug or food allergies reported.

-Relevant family history: Not specified.

Physical Examination:

Vitally is stable as above, seems in general: Alert, appears uncomfortable. No acute distress noted or diaphoresis.

Cardiovascular: BP 145/90, HR 97. Regular rate and rhythm, heart sounds normal, no murmurs or gallops. No jugular venous distention.

Respiratory: RR 20, SpO2 94% on room air. Clear breath sounds bilaterally, no crackles or wheezing.

HEENT: Normocephalic, atraumatic. Pupils equal and reactive.

Neck: No carotid bruits, JVB normal, trachea midline.

Abdomen: Soft, lax, non-tender.

Extremities: No edema, peripheral pulses intact.

Neurological: Alert and oriented, cranial nerves grossly intact.

DDX: 

Differential diagnosis includes but is not limited to; ACS, aortic dissection, pneumonia, pneumothorax, and costochondritis.

ECG: no ST-Elevation, but T-wave inversion led V2 and V3

CXR: shows no signs of pneumonia, pneumothorax, pulmonary edema, pleural effusion, or pneumomediastinum.  

LAB: with in normal.

Assessment: Low risk ACS.

Chest Pain; Disposition Consultant Note:

?? y/o male with PMH of DM, HTN, Dyslipidemia, obesity and smoker, who presents with gradual onset of prusser like chest pain which continuous, 7/10 in severity .   

Physical Exam: 8 system physical exam, at least 2 points for each system. MDM: Brief summary.  

Differential diagnosis includes but is not limited to ACS, aortic dissection, pneumonia, pneumothorax, and costochondritis. 

Patient is hemodynamically stable, has no neurologic deficits, and the chest pain is resolved making aortic dissection unlikely. Pulmonary embolism is unlikely based on lack of dyspnea, pleuritic chest pain, and tachycardia. Doubt pneumothorax with normal lung sounds and lack of dyspnea. Esophageal rupture is less likely with no hematemesis and no dysphagia. Patient has no signs of infection with lack of fever, chills, and productive cough, which makes pneumonia unlikely.  

Patient was administered 325mg PO aspirin. EKG showed normal sinus rhythm with no ST segment changes. In order to further evaluate for possible ACS, a troponin was drawn and also negative.

Through the HEART score pathway, the patient is overall low risk with an initial HEART score of 2 and negative troponin set. 

CBC shows no anemia or leukocytosis. BMP shows no electrolyte abnormalities or AKI. 

CXR shows no signs of pneumonia, pneumothorax, pulmonary edema, pleural effusion, or pneumomediastinum.  

DDx - What you think could be going on. Ruling in/out major life-threatening diagnosis. 

Narrative - ED course, which includes treatments given and test results. Discuss final disposition including information such as prescriptions, follow-up instructions, and return precautions if the patient is being discharged.  

D/C Note:

Upon re-evaluation, the patient reports no return of chest pain. He continues to appear well and a repeat cardiovascular and respiratory exam reveals improved chest wall tenderness. His vital signs have remained stable throughout his ED course. Patient was instructed to follow up with his PCP within 1-2 weeks. He was discharged home in stable condition with appropriate return precautions. Impression:  low risk ACS, with follow up with one week.