Subjective (S):

  • Chief Complaint (CC): Sean reports experiencing chest pain three days ago.
  • History of Present Illness (HPI): Sean is a 52-year-old male with a history of hypertension (HTN) who presents with concerns about chest pain that occurred three days ago. He reports that his lisinopril was discontinued three months ago. He also has elevated cholesterol levels, which he is currently managing through diet, exercise, and other lifestyle changes. The chest pain episode included shortness of breath, sweating, nausea, and a heavy feeling in his chest, lasting about 3 minutes. He is now concerned about increasing fatigue during physical activity.
  • OLDCART/ROS:
    • Onset: 3 days ago.
    • Location: Chest.
    • Duration: Lasted 3 minutes.
    • Characteristics: Shortness of breath, heavy chest feeling, nausea, sweating, and fatigue.
    • Aggravating Factors: Increased tiredness.
    • Relieving Factors: Resolved on its own; no recurrence.
    • Treatment: None.
    • Severity: Fatigue has led to shorter workouts since the episode.
  • Questions for Further Evaluation:
    • Is the pain localized or more generalized?
    • Does the pain radiate to the back, shoulder, or jaw?
    • What are the circumstances of the pain onset (activity, food)?
    • Recent weight loss? Changes in exercise routine?
    • History of elevated cholesterol or coronary heart disease?
    • Family history of heart disease, heart attack, HTN, or hyperlipidemia?
    • Current medications, diet, smoking habits, alcohol intake?
  • Current Medications: None (Lisinopril discontinued 3 months ago).
  • Allergies: None known (NKDA).
  • Immunizations: Does not receive the flu shot.
  • Past Medical History (PMH): Childhood chickenpox, hypertension, elevated cholesterol managed through lifestyle changes.
  • Surgical History: Tonsillectomy (T&A), cholecystectomy, vasectomy.
  • Social History (SH): Married for 20 years, works as a mortgage broker. Enjoys alcohol socially and the occasional cigar. Exercises regularly but has recently reduced intensity.
  • Family History (FH):
    • Father: Deceased, history of lung cancer.
    • Mother: Deceased, complications from a stroke.
    • Brother: Deceased at 44 from malignant melanoma.
    • Other siblings: Healthy.
  • Review of Systems (ROS):
    • Constitutional: Sweaty, no fever or chills.
    • HEENT: Dizziness, no headaches, no visual changes, ear pain, nasal drainage, or sore throat.
    • Cardiovascular: Chest pain, palpitations, no edema in lower extremities.
    • Respiratory: Shortness of breath on exertion, no wheezing, cough, or hemoptysis.
    • Gastrointestinal: Nausea, no vomiting or diarrhea, decreased appetite.
    • Genitourinary: No dysuria, urgency, or urinary incontinence.
    • Neurological: Fatigue, no lethargy, weakness, speech difficulties, gait problems, or peripheral tingling.
    • Integumentary: No rash.
    • Musculoskeletal: No muscle pain.
    • Hematologic/Lymphatic: No rash, bruising, or swollen/tender nodes.
    • Psychiatric: No anxiety or depression.
Objective (O):
  • Physical Exam:
    • General: Caucasian male, alert, oriented, and cooperative. No acute distress (NAD). Pain level: 0/10 currently.
    • Vital Signs: Height: 5’11”, Weight: 192.2 lbs, BMI: 26.8 (overweight). BP: 136/84, Pulse: 70, SaO2: 97%.
    • Skin: Warm, dry, intact, pale pink; no cyanosis or pallor.
    • HEENT: Normocephalic, clear sclera, white conjunctiva, PERRLA, EOMs intact, tympanic membranes gray/intact, no tenderness in pinna/tragus, patent nares, no sinus tenderness, oropharynx moist, no lesions/exudate, tongue midline, thyroid midline and firm.
    • Pulmonary: Lungs clear bilaterally, respirations unlabored, no chest rashes or vesicles.
    • Cardiovascular: S1 and S2, regular rate and rhythm (RRR), no murmurs, no parasternal lifts/heaves/thrills, equal peripheral pulses bilaterally, PMI at 5th ICS, no lower extremity edema.
    • Abdomen: Round, soft, bowel sounds present in all four quadrants, no organomegaly.
  • Labs from 3 Months Ago:
    • Total Cholesterol (TC): 230
    • LDL: 180
    • HDL: 38
  • In-Office EKG: Shows ST depression.
Assessment (A):
  • Primary Diagnosis: Non-ST Segment Elevation Myocardial Infarction (NSTEMI) ICD-10: I21.4 Rationale: Sean presents with a history of hypertension, dyslipidemia, and recent chest pain associated with symptoms indicative of myocardial ischemia (shortness of breath, nausea, sweating). The in-office EKG showing ST depression further supports this diagnosis. The cessation of antihypertensive medication and elevated cholesterol levels increase his risk of coronary artery disease and subsequent myocardial infarction.
  • Secondary Diagnosis: Dyslipidemia ICD-10: E78.5 Rationale: Sean’s lab results indicate elevated total cholesterol, high LDL, and low HDL levels. Despite lifestyle management, these values suggest that diet and exercise alone may not be sufficient for controlling his dyslipidemia, which likely contributed to his NSTEMI.
  • Differential Diagnosis:
    • Peptic Ulcer Disease (PUD), Acute Without Hemorrhage or Perforation ICD-10: K27.3 Rationale: PUD can present with epigastric pain that may be mistaken for non-cardiac chest pain. Sean’s symptoms of nausea and chest discomfort could be suggestive of PUD, but the lack of typical GI symptoms (e.g., heartburn, indigestion) and the presence of cardiac risk factors makes this less likely.
Plan (P):
  • Immediate Action:
    • Send Sean to the nearest emergency department (ED) for further evaluation and management, given the high risk of a major cardiac event.
    • Inform the ED about Sean’s condition, including his recent NSTEMI symptoms and EKG findings.
  • Diagnostics:
    • In the ED: Expect further diagnostics such as a full lipid panel, HbA1c (if not done recently), routine chemistries, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and cardiac enzyme levels (CKMB, Troponin). A chest X-ray may be ordered to assess for cardiomegaly, pericardial effusion, or acute pulmonary edema.
  • Medications:
    • In the ED: Sean may receive aspirin (325 mg stat, then 75 mg daily), clopidogrel (600 mg now, then 150 mg daily x 7 days and 75 mg daily), and carvedilol (25 mg PO BID). Nitroglycerin sublingual (0.3 mg q5min for chest pain) and simvastatin (40 mg PO daily) may be initiated, along with lisinopril (10 mg PO daily) for hypertension management.
  • Referrals:
    • Referral to a cardiologist for further evaluation, including a possible stress test, echocardiogram, and other cardiac assessments.
  • Patient Education:
    • Educate Sean on the severity of his condition and the importance of immediate medical attention if similar symptoms occur in the future.
    • Discuss the need for strict adherence to prescribed medications, lifestyle modifications, and regular follow-up with his healthcare provider.
    • Recommend smoking cessation, a low-cholesterol diet, regular physical activity, and maintaining an ideal BMI.
    • Introduce Sean to the DASH diet and emphasize the importance of managing his blood pressure through regular monitoring and medication compliance.
  • Follow-Up:
    • After discharge from the hospital, Sean should return to the clinic for a follow-up visit. At that time, we will review his care plan, evaluate medication compliance, and assess for any further cardiac risk factors or complications.
References:
  • Cayla, G., Silvain, J., Collet, J.-P., & Montalescot, G. (2015). Updates and current recommendations for the management of patients With Non–ST-Elevation Acute Coronary Syndromes: What It Means for Clinical Practice. The American Journal of Cardiology, 115(5), 10A–22A. doi:10.1016/j.amjcard.2015.01.003
  • Davis, A. (2012). Drug metabolism and pharmacokinetics quick guide. ChemMedChem, 7(4), 741–742. doi:10.1002/cmdc.201200027
  • Hendrani, A. D. (2016). Dyslipidemia management in primary prevention of cardiovascular disease: Current guidelines and strategies. World Journal of Cardiology, 8(2), 201. doi:10.4330/wjc.v8.i2.201
  • Marsden, J. (2014). Mosby’s Manual of Diagnostic and Laboratory Tests Pagana Kathleen and Pagana Timothy. Elsevier. Emergency Nurse, 22(4), 13–13. doi:10.7748/en.22.4.13.s14
  • Yuan, X., Xie, C., Chen, J., Xie, Y., Zhang, K., & Lu, N. (2014). Seasonal changes in gastric mucosal factors associated with peptic ulcer bleeding. Exp Ther Med. doi:10.3892/etm.2014.2080