Subjective:

CC: Pt states I have experienced a couple episodes of chest pain accompanied by L arm
numbness and dizziness.

HPI: Pt is a 57-year-old male presenting to the Emergency Department with a history of 2

episodes of substernal chest pain starting 3 days ago. Pt denies pain during the visit. The chest
pain came while walking up a hill for work and was relieved by rest and after taking an aspirin.
The chest pain was accompanied by numbness of the left arm and dizziness, that also subsided
with rest. The onset of the chest pain was sudden. The patient admits to dyspnea on exertion,
but denies palpitations. There have been separate episodes of dizziness. The patient does not
currently see a primary care provider or a cardiologist.

PMHx:
- Medical: Pt denies any current or past medical problems, pt states he has not been to the
doctor in years. Denies any known problems of hyperlipidemia or HTN.
- Surgical: Appendectomy at age 13
- Medications: Currently taking ASA prn for chest pain complaint
- Allergies: NKDA

Family Hx:
- Denies family hx or cardiovascular disease

Social Hx:
- Current smoker.

ROS:
- General: Denies anorexia, chills, diet changes, fever, fatigue, weight change.
- Skin: Denies clamminess or swelling.
- Respiratory: Complains of dyspnea on exertion and productive cough. Current smoker.
- Cardiovascular: Complains of substernal chest pain, accompanied by right arm
numbness, brought on by exertion and relieved by ASA and rest. Complains of
dizziness, but denies syncope. Denies palpitations, intermittent claudication.
- MSK: Denies any muscle weakness or joint pain. Denies previous injury.

Objective:
Physical Exam
- Vitals
o Temp: 97.3
o Pulse: 76
o Respirations: 16
o BP: 144/82
o SpO2: 98%
o Weight: 241lbs
- General: A & Ox4. Cooperative, general appearance consistent with age. Pt is not in any
acute distress and looks well. Well groomed. Pt was smiling and laughing throughout the
entire encounter.
 - Chest/Lung: Chest well symmetrical, no scars. No use of accessory muscles. Non-tender
chest wall. Diffuse wheezing heard bilaterally.
- Cardiovascular: RRR. S1S2 heard. No murmurs, rubs or gallops. No edema noted.

Assessment:
- Chest pain with typical features (ordered EKG)
- Tobacco abuse
- Troponin lab draw

Plan:
- Chest pain with typical features: A EKG was ordered due to the pts chest pain
complaint. There were no acute changes on the EKG, and the results were addressed
with the physician. Baseline labs were ordered for the patient since he hasnt seen a
doctor in years. A cardiac stress test was ordered. The pt is to remain on 81mg of ASA
and an appointment with a primary care provider was scheduled for the following week.
The patient and his wife were repeatedly educated on the importance of coming back to
the emergency room if he had symptoms like this again, they acknowledged that they
understood the importance and agreed to go to the ER if the sxs came back.
- Tobacco abuse: Educated on the importance of decreasing his tobacco use, especially
with the dangers it causes the heart. Prescribed albuterol prn.