Date of Service: 04/07/2019

Setting: Inpatient

Patient’s name: Mr. X

Age: 50 y/o
Sex: Male
Source of Information: Patient

Patient’s Chief Complaints:

“I’m having pain in my chest and it goes up into my left shoulder and down the inside of my left arm.
I’m also having a hard time catching my breath and I feel somewhat sick to my stomach.”

History of Present Illness

Mr. X is a 50-year-old white man who began to experience chest discomfort while playing tennis
with a friend. At first, he attributed his discomfort to the heat and having had a large breakfast.
Gradually, however, discomfort intensified to a crushing sensation in the sternal area and the pain
seemed to spread upward into his neck and lower jaw and was associated with dyspnea, nausea,
and diaphoresis. The chest pain was a 9 on a 10-point scale. The patient was transported to the ED
of the nearest hospital and arrived within 30 minutes of the onset of chest pain. He notes the pain
seemed to get worse with any movement, and nothing seemed to alleviate it. The nature of the pain
did not seem to change with deep breathing. He notes a similar chest pain that was less and intense
and occurred intermittently over the last 3 months. He denies seeking medical attention in the past.
He denies a history of orthopnea, paroxysmal nocturnal dyspnea, dyspnea on exertion, or pedal
edema. He has smoked two packs of cigarettes per day for 30 years, notes a 2-year history of
hypertension for which he has been taking HCTZ 25mg/d, has a history of GERD, and denies a history
of hypercholesterolemia or diabetes.