Clinical Note

Age      58            Sex            M       

Chief complaint Chest pain

History of present illness

Three months following his first visit to your office, Mr. Solomon presents to Loyola’s emergency room, in the early morning, with chest pain of one hour duration. Mr. Solomon describes the pain as being severe and "like someone was sitting on his chest." The pain, located "in the lower part of my breast bone," awakened him from his sleep. Although he tried to relieve the pain by changing positions in bed, sitting up and drinking water, it remained unchanged. He did not sleep well because "I had an upset stomach an acid-burning feeling." He attributed these symptoms to over eating and drinking at a Christmas party. He has no pain or discomfort in his arms but says he has an "acheness" in his left jaw which he attributes to "bad teeth."

Physical examination reveals the patient to be anxious, pale, diaphoretic and in obvious discomfort. He is unshaven and accompanied by his wife. He tries to relieve his pain by belching. He coughs occasionally. Mr. Solomon says "the flu has been going around the office, and I’ve had a little cough and fever all week."

Vital signs: BP in the right arm 130/90 mmHg, BP in left arm 128/96 mmHg; respiratory rate 20/minute; temperature 99º F. Examination of the lungs reveals normal resonance and vesicular breath sounds bilaterally; an occasional inspiratory crackle is heard but is cleared with coughing. Examination of the cardiovascular system reveals an apical rate of 90/minute with occasional premature contractions. Neck veins are not distended. Auscultation reveals a normal S1 and S2. An S4 is heard best in the 5ICS, MCL. There are no murmurs or S3. There is no peripheral edema.

Examination of the abdomen reveals the anterior wall to be flat and soft. There is no tenderness, organomegaly or palpable masses. Bowel sounds are normal. The skin is cool and moist.

ADMISSION LABORATORY TESTS:

CBC:

Leukocyte count = 12,000 mm3 (Neutrophils 72%, Lymphocytes 22%, Eosinophils 1%, Monocytes 5%)
Hemoglobin 15.5g/dL, Hematocrit 46%
Platelet count 296,000/mm3

Chemistries:

Glucose 101mg/dL; Blood Urea Nitrogen (BUN) 15.8mg/dL; Creatinine .8mg/dL, Electrolytes = Soduim 141 mEq/L, Chloride 101 mEq/L, Potassium 4.2 mEq/L, Bicarbonate 24 mEq/L. Enzymes are pending.

Chest X-ray:

"Within Normal Limits"

Electrocardiogram: *

Refer to attached sheets.

Catheterization Data: A review of Mr. Solomon's old chart reveals that he was catheterized several months ago. The catheterization revealed an 80% narrowing of the LAD and a 50% narrowing of the RC.

* Refer to Function of the Human Body Course handout on electrophysiology and to the software program"Interpretive Electrocardiography" on our computer system.