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PATIENT PRESENTATION

Chief Complaint

“I have been having chest pain off and on since waking up this morning.”

History of Present Illness

KT is a 62-year-old white male who presents to the emergency department with intermittent 9/10 chest pressure that radiates to his left jaw and shoulder, nausea, shortness of breath, and dizziness. His symptoms started upon waking about 6 hours ago. He reports four episodes of discomfort since this morning that suddenly come and go; the episodes last no longer than 10 to 20 minutes. The patient is given aspirin (chewed) 325 mg by mouth × 1 and is started on oxygen, nitroglycerin (NTG) 5 mcg/min gtt, and enoxaparin 100 mg subcutaneously twice daily. Stat labs and an EKG are ordered.

Past Medical History

Depression

Diabetes mellitus (DM) type 2

Dyslipidemia

Hypertension (HTN)

Hypothyroidism

Osteoarthritis (bilateral knees)

Surgical History

Rotator cuff repair

Family History

Father had a myocardial infarction (MI) at 54 years old

Social History

Married with three daughters.

Works as a computer consultant.

Lives a sedentary life.

Drinks 1 to 2 bourbons per night.

Quit smoking 10 years ago (30 pack/year history).

Immunization

Up to date

Insurance

Blue Cross/Blue Shield

Allergies

Penicillin (hives)

Home Medications/supplements

  • Atorvastatin 20 mg PO daily

  • Glucosamine 1500 mg/chondroitin 1200 mg PO daily

  • HCTZ 25 mg PO daily

  • Ibuprofen 400 mg PO every 6 hours as needed knee pain

  • Levothyroxine 88 mcg PO daily

  • Lisinopril 20 mg PO daily

  • Metformin ER 1000 mg PO daily

  • Multivitamin PO daily

  • Sertraline 50 mg PO daily

  • Turmeric 100 mg PO daily

Physical Examination

Vital Signs

Temp 97.6°F, P 116, RR 28, BP 162/102 mmHg, pO2 98%, Ht: 6′1″, Wt: 100.4 kg

General

Well nourished, overweight male in moderate distress.

HEENT

PERRLA, EOMI.

Pulmonary

Increased respirations, lungs are clear to auscultation bilaterally.

Cardiovascular

Tachycardic, t-wave inversions in lateral leads, no m/r/g.

Abdomen

Soft, non-distended, nontender, normal bowel sounds.

Genitourinary

Normal male genitalia, no complaints of dysuria or hematuria.

Neurologic

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