Identifying Data:

Age: 77

Sex: male

Date of encounter: Tuesday,  May 31, 2022

Location: NYPQ ED

Race: Hispanic

Source of Information: self

Reliability: reliable

Source of Referral: self

 

Chief Complaint: Chest pain since 5AM today

 

History of Present Illness:

Pt is a 77 y/o male with PMH of CAD s/p PCI x5 (most recent in 2006), GERD, HLD, DM2, GAD, cholecystectomy, presenting to the ED for lower sternal chest and epigastric pain that began at 5AM this morning. Pain is described as waxing and waning, heaviness/pressure-like in quality, radiating to his back, now 8/10 severity. He tried taking aspirin and SL nitroglycerin without relief. No alleviating or exacerbating factors. Pt mentions this pain does not feel similar to his GERD or previous heart attacks. He denies SOB, DOE, palpitations, leg swelling, syncope, nausea, vomiting, diarrhea, constipation, fever, chills, cough. Of note, pt mentions drinking heavily over the weekend (5 glasses of wine Saturday, 2 glasses Sunday, 4 beers yesterday, and 2 glasses of wine today). He states he used to drink heavily about 5 years ago but has since cut down to only drinking for special occasions. Otherwise, no recent travel or known sick contacts.

 

Past Medical History:

CAD

GERD

HLD

Diabetes mellitus type 2

Generalized anxiety disorder

Immunizations – up to date, including COVID x3

 

Past Surgical History:

Cholecystectomy (1997)

PCI x5 (most recent in 2006)

 

Medications:

Clonazepam – 0.5mg  PO BID as needed.

Farxiga(dapagliflozin) – 5mg PO daily

Pantoprazole – 40mg PO daily, 30 minutes before breakfast

Prasugrel – 5mg PO daily

Rosuvastatin – 20mg PO daily

Trulicity(Dulaglutide) – 1.5mg/0.5mL solution pen injector, inject 0.5mL every week

Vascepa – 1g PO daily

 

Allergies:

Denies any drug, environmental, or food allergies.

 

Family History:

Brother and mother with diabetes.

 

Social History:

Patient lives with his wife. He is able to complete ADLs independently.

Habits –Denies smoking history. (+)alcohol use – states he used to drink heavily but stopped about 5 years ago. Now only drinks for special occasions, but admits to drinking more than usual over the last weekend. Denies history of illicit substance use.

Sleep – no complaints

Travel – No recent travel.

 

Review of Systems:

General – Denies recent fever, chills, weight loss/gain, fatigue, sweats, or change in appetite.

Skin/nails – Denies rash, change in pigmentation.

Head – Denies headache, dizziness, lightheadedness, recent head trauma.

Eyes – Denies visual disturbances.

Nose – Denies congestion, rhinorrhea.

Mouth/throat – Denies sore throat, difficulty swallowing.

Neck – Denies pain, stiffness.

Pulmonary – Denies SOB, DOE, cough, wheezing, orthopnea. Sleeps with 1 pillow for comfort.

Cardiovascular – (+)chest pain. Denies palpitations, lower extremity swelling, syncope.

GI – (+)abdominal pain. Denies nausea, vomiting, diarrhea, constipation, blood in stool. No recent changes in BM.

Genitourinary – Denies dark urine, incontinence, urgency, dysuria, hematuria, frequency.

Nervous – Denies tingling, seizures, confusion, weakness, numbness, gait change.

Musculoskeletal – (+)back pain. Otherwise denies body aches.

 

 

Physical Exam:

Vital signs:      BP: Seated              R-arm: 150/78

RR:      16 breaths/min, unlabored

Pulse: 85 bpm, regular

T:        36.6 degrees C (oral)

O2 Sat: 97% on room air

Height: 5 ft 7 inches        Weight: 145 lbs.       BMI: 22.7

 

General: Pt alert, oriented. Appears uncomfortable due to pain. Well nourished. Looks stated age.

Skin: No diaphoresis. Skin is warm. No ecchymosis. Nonicteric, no other lesions noted, no tattoos. No rashes appreciated.

Hair:  Male pattern baldness

Nails:  no clubbing, capillary refill <2 seconds in upper and lower extremities.

Head:   normocephalic, atraumatic, nontender to palpation throughout

Ear: Symmetrical and appropriate in size.  No lesions, masses, trauma on external ears. No hearing aid

Nose – Symmetrical. No masses, lesions, deformities, trauma, discharge. Nares are patent bilaterally.

Nasal mucosa pink & well hydrated. No discharge noted.

Mouth/Oropharynx – Lips appear pink and moist, with no masses, cyanosis, or ulcers. Mucosa pink and moist. No lesions or masses. No leukoplakia. Palate pink, moist, intact with no lesions, masses, or scars.

No gingival hyperplasia or recession.

Tongue is midline. No discharge, masses or lesions.

Uvula is midline and rises symmetrically with phonation. No edema or lesions.

Oropharynx is pink and moist. Tonsils are symmetric and without hypertrophy. No swelling, erythema, exudates, masses/lesions, foreign bodies.

Neck – Supple. Non-tender to palpation. Trachea is midline. No masses or lesions. Lymph nodes non-palpable bilaterally. No stridor. 2+ carotid pulses bilaterally. No cervical adenopathy noted.

Eyes – Eyelids without lesions, edema, or discharge. No strabismus, exophthalmos or ptosis.  Sclera white, conjunctiva pink bilaterally.

Chest/Pulmonary: Chest is symmetrical, without deformities or trauma. Lat to PA diameter is 2:1. Respirations unlabored. No use of accessory muscles noted. Chest nontender to palpation throughout. Lungs CTA bilaterally. No wheezes, rhonchi, rales, or other adventitious sounds.

Heart: Regular rate and rhythm. Distinct S1 and S2. No murmurs, S3, S4, friction rubs, or splitting of S2 appreciated. PMI in 5^th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits.

Abdomen: (+)epigastric tenderness.  No guarding or rebound. Rest of abdomen nontender to palpation. Tympanic throughout. No hepatosplenomegaly. Abdomen flat, soft, symmetric. No scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants. No CVA tenderness noted.

Mental Status Exam: Appearance and behavior – patient alert, no abnormal movements, grooming/hygiene appropriate, appropriate facial expression and manner.

Speech and language – follows 3 stage commands. Speech is of appropriate quantity, rate, volume, flow, and articulation.

Oriented to name, date, time, location.

Neurologic:

Cranial Nerves –See “Eyes” for CN II assessment. Conjugate gaze without nystagmus. No ptosis. Symmetric and fluid facial movements. No difficulty with BMP speech sounds.

Soft palate rises and uvula remains midline. No hoarseness or nasal quality in voice. No facial droop. No difficulty with LTND speech sounds.

Peripheral Neuro –

Motor/Cerebellar

Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Gait steady with no ataxia.

Musculoskeletal: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM (Full Range of Motion) of all upper and lower extremities bilaterally.

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PROGRESS NOTES:

20:37 – EKG: sinus bradycardia at 58bpm. Normal axis. Normal intervals. No ST elevations or depressions.

 

20:56 – BMP WNL (except glucose 149), CBC WNL

LFTs: AST 125,  ALT 83, otherwise WNL

Trop: <0.010               ProBNP 48 (ref range 0-450)

COVID negative         Lipase >3000 (ref range 13-60)          Amylase 1,598 (25-124)

TG 131                        LDH 258 (135-225)

 

23:58 – CXR “vague left basilar opacity, atelectasis versus pneumonia. Follow-up, perhaps after course of treatment, is suggested to document resolution and to exclude superimposed abnormalities.”

 

3:36 – CT A/P w IV contrast: “Findings consistent with acute pancreatitis involving the head and uncinate process regions, with secondary inflammation of the duodenum. Stable mild dilatation of the intrahepatic biliary tree and common bile duct, possibly related to prior cholecystectomy. Colonic diverticulosis without CT findings of acute diverticulitis. Possible changes of gastritis. Marked prostatic enlargement with changes of chronic bladder outlet obstruction.  Left inguinal hernia containing fat and small portion of nonobstructed sigmoid colon.”

 

 

Differential Diagnoses:

• Pancreatitis
• Gastritis
• GERD
• Choledocholithiasis
• ACS
• Pneumonia
• Anxiety

Assessment/Plan:  77 y/o male with PMHx of CAD s/p PCI x5, GERD, DM2, cholecystectomy, with chest and epigastric pain radiating to back since this morning. EKG without STEMI and trop negative. Amylase and lipase elevated. CT A/P suggests acute pancreatitis; likely secondary to recent EtOH use. Plan for pain control, IV fluids, NPO, alcohol cessation counseling, general surgery consult.