History

HPI: 46 yo M c/o substernal chest pain. The pain started 40 minutes before
he patient presented to the ED. The pain woke the patient from sleep at 5:00
A.M. with a steady 7/10 pressure sensation in the middle of his chest that
radiated to the left arm, upper back, and neck. Nothing makes it worse or
better. Nausea, sweating, and dyspnea are also present. Similar episodes have
occurred during the past 3 months, 2-3 times/week. These episodes were
precipitated by walking up the stairs, strenuous work, sexual intercourse, and
heavy meals. Pain during these episodes was less severe, lasted for 5-10
minutes, and disappeared spontaneously or after taking antacids.
ROS: Negative except as above.
Allergies: NKDA.
Medications: Maalox, diuretic.
PMH: Hypertension for 5 years, treated with a diuretic. High cholesterol,
managed with diet. GERD 10 years ago, treated with antacids.
SH: 1 PPD for 25 years; stopped 3 months ago. Occasional EtOH, occasional
cocaine for 10 years (last used yesterday afternoon). No regular exercise; poor
l y adhe r e nt t o di e t .
FH: Father died of lung cancer at age 72. Mother has peptic ulcers. No early
coronary disease.

Physical Examination
Patient is in severe pain.
VS: BP 165/85 mm Hg (both arms), RR 22/minute.
Neck: No JVD, no bruits.
Chest: No tenderness, clear symmetric breath sounds bilaterally.
Heart: Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs,
or gallops.
Abdomen: Soft, nondistended, nontender,
BS, no hepatosplenomegaly.
Extremities: No edema, peripheral pulses 2+ and symmetric.

Differential Diagnosis