Date: 09/14/2021
Hospital Visit (Emergency Room)
Identifying data:
Full name: Mr. MJ
Address: Queens, NY
Date of Birth: 12/30/1992
Location: New York-Presbyterian, Flushing, NY
Religion: non-religious
Source of Information: Self
Reliability: Reliable
Source of Referral: none
Mode of Transport: Self
Chief Complaint: “I have pain around my heart” x 3 day ago.
History of Presenting Illness:
Patient is a 29-year-old male with PMHx of atrial fibrillation, asthma and sleep apnea presents to the ED today with complaints of chest pain and pain which he points to around his mid back. The patient states he has never experienced this pain in the past and states he first noticed this pain in x 3 days ago, but states it was on and off. Pt states today he woke up around 6am due to the pain. He states today the pain was constant but stopped for 15 minutes and came back but is still present. He describes the pain as sharp and repeatedly point to his mid back bilaterally. He describes the pain as being 4/10 currently but the worst occasion was 7/10. He denies taking anything to relieve the pain. He states the pain feels worse when he breathes, slouches, or lays down. He states the pain is less severe when he sits up right. Denies any pain with eating. The patient states he suspects the pain may be due to poor posture because his 2-year-old son sleeps on his back sometimes. The patient denies any recent strenuous activity but states that he had contacted covid x 5 months ago. The patient is not covid vaccinated. The patient denies any rhinorrhea, cough, sob, dyspnea, fever, chills, nausea, and vomiting. The patient denies any further complaints.
Past Medical History:
-Asthma x in childhood but has not had any attacks since.
-Atrial fibrillation x “few years ago” (Patient was offered blood thinners and was recommended to undergo and ablation but he denies both options)
-Sleep apnea x 4-5 years ago.
Past Surgical History:
-Drainage of under arm cyst x “few years ago”
Medications:
-Denies use of any medications
Allergies:
-Denies any allergies to medication
-Denies any food and environmental allergies
Family History:
Mother – denies any history
Father –denies any history
Brother–denies any history.
Son- Asthma
Social history:
-He has a girlfriend and has a 2-year-old son with astha,
-Drinks socially
-Denies any smoking history.
-Work- States he is unemployed at the time.
Review of system:
General – denies generalized weakness/fatigue, chills, or fever
Skin, hair, and nails- denies diaphoresis, denies any recent trauma, denies any discoloration to skin
Head – Denies headache, denies vertigo
Eyes – Denies any recent visual changes. Does not wear corrective lenses
Ears – denies deafness, denies ringing in ears, denies pressure or pain
Nose /Sinuses – denies rhinorrhea, denies facial pain or pressure
Mouth/ throat – denies tonsillectomy, denies any oral pain,
Neck- denies any pain
Breast – denies any pain, discharge, or changes
Pulmonary system- Has history of asthma, denies dyspnea, cough, shortness of breath. Has history of sleep apnea but does not use any treatment. Ha
Cardiovascular system-complains of chest pain but points towards mid back, denies any palpitations
Gastrointestinal system – denies nausea, vomiting,
Genitourinary system –denies nocturia or dysuria
Menstrual /obstetrical – not applicable
Nervous -Denies headache, loss of consciousness, facial and general weakness
Musculoskeletal- denies any muscle/ joint pain but points to midback as location of the pain
Peripheral vascular system – denies calf pain, swelling of feet
Hematological -denies any recent trauma
Endocrine system – denies nocturia
Psychiatric – denies any depression or anxiety
Physical exam:
Vital signs:
L (supine): 130/82mmHg
Pulse: 68 bpm, regular
RR: 14/min unlabored
T: 36.8 Celsius orally
O2 sat: 98% on room air
BMI: 25.1 kg/m2 (weight: 175lbs, Height: 5’10)
General: Hispanic, overweight male, is alert and oriented to person, place, and time (x3), neatly groomed, appears as stated age, appears in no acute distress
Skin, hair, and nails: Skin appears to be of even skin tone, good skin turgor, hair is evenly distributed on head and across arms and upper body, no Jaundice or unusual discoloration. No bruising noted along arms and face. No Jaundice noted. No splinter hemorrhages, clubbing or spoon nails.
Head: No moon facies, acromegaly. No masses or lesions noted on the face. No tenderness to palpation of the head. Black hair, not brittle and well distributed. No seborrhea, lice, or mites. No bruising, or lacerations noted.
Eyes: No lacrimation. No Jaundice. No periorbital swelling, no strabismus.
Ears: No mastoiditis or swelling and erythema noted around the auricle. No tenderness to palpation of the auricle. Tympanic membrane is intact, no fluid behind, no erythema in ear canal. Cone of light seen at 7 o’clock in left ear and 5’oclock position in right ear. No periauricular sinus
Nose: Patent bilaterally. No external lesions or masses noted. No notable rhinorrhea. No tenderness to palpation around the maxillary and frontal sinuses.
Neck: No lymphadenopathy noted. No tenderness to palpation.
Mouth: No central cyanosis around the lips.
Pulmonary: Clear to auscultation Bilaterally. No wheezing, rales, rhonchi, or stridor.
Cardiovascular: Normal S1 and S2 sounds. No JVD noted. No thrills and heaves.
Abdominal exam: present bowel sounds in all four quadrants, no pain with light and deep palpation. No Murphy’s signs. Negative McBurney’s test point. No ascites noted. Tympany was noted in all four quadrants.
Assessment:
29-year-old male with PMHx of atrial fibrillation, asthma and sleep apnea presents to the ED today with complaints of chest pain and pain which he points to around his mid back x 3 days. Pt is unvaccinated for covid and the flu.
Differential:
- Musculoskeletal pain: High suspicion that they pain may be due to poor posture as he described in his story.
- Pleurisy: Moderate suspicion -considering pleurisy because of the location of pain and the complaint that the pain appears to be worsened with certain positional changes and when breathing deeply.
- Covid-19: Considering that it could be a potential sequalae of contacting covid
- Pneumonia: Very unlikely as the patient denies any cold symptoms, fever, and the normal lung exam.
- Influenza: Also, very unlikely for similar reasons as the pneumonia differential.
Plan:
-Musculoskeletal chest/back pain: EKG, administer ibuprofen
-Atrial fibrillation: EKG (normal), counsel to consider blood thinners or ablation
-Sleep apnea: Recommend inspire implant
-Covid-19: Counsel about the benefits of vaccination and to get vaccinated
-Pleurisy: EKG, CXR, CBC
-Flu- Counsel to get the flu vaccination
