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| HPI |
DJ is a 67-year-old male who presents to the emergency department having a 30-minute episode of chest pain, which began while he was walking down his driveway. The pain was described as a "pins and needles" sensation. The pain radiated down both his arms, he became diaphoretic and dyspneic. The pain was not pleuritic and resolved shortly after resting. The previous day he had a similar episode.
He denies nausea, vomiting, fever, cough or any GI complaints. He denies recent upper respiratory infections.
His past medical history is significant for hypertension and hypercholesterolemia. He hasn't smoked in "many years" and denies drug use.
He presently takes atenolol and lovastatin. Family history is significant for a brother who had a Coronary artery bypass grafting at age 50. He has no known allergies.
On physical examination he is an anxious, thin male who looks appropriate for age.
His vitals are as follows: BP 160/96, pulse 60, respirations of 18, oxygen saturation of 98%(room air) and temperature of 37.3.
His external jugular veins are not distended. He has clear lung sounds and his chest is nontender to palpation. Cardiovascular exam reveals a slow, regular rate and rhythm with no murmurs, gallops or rubs. His abdomen is soft and non-tender. The skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his exam in unremarkable. His EKG is shown below. While in the emergency department he says that his pain is returning.
