“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.
Diabetes mellitus (DM) type 2
Osteoarthritis (bilateral knees)
Father had a myocardial infarction (MI) at 54 years old
Married with three daughters.
Works as a computer consultant.
Drinks 1 to 2 bourbons per night.
Quit smoking 10 years ago (30 pack/year history).
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
Temp 97.6°F, P 116, RR 28, BP 162/102 mmHg, pO2 98%, Ht: 6′1″, Wt: 100.4 kg
Well nourished, overweight male in moderate distress.
Increased respirations, lungs are clear to auscultation bilaterally.
Tachycardic, t-wave inversions in lateral leads, no m/r/g.
Soft, non-distended, nontender, normal bowel sounds.
Normal male genitalia, no complaints of dysuria or hematuria.