Chief Complaint

“I don’t feel well at all, my chest feels so tight and pain as well.”

HPI

A 56-year old lady paid a visit to the emergency department, with the complaint of retrosternal
chest pain during brisk walking. The chest pain increased in late afternoon, which improves with
rest, it no longer completely resolves and increased till evening so relatives called an ambulance.

The chest pain was associated with a sensation of suffocation and choking. The chest pain
radiated towards the left shoulder, down the inner aspect of the left arm as well as to the neck
and lower jaw. There was no history of dyspnea, palpitation, excessive sweating or syncope. The
pain typically occurred when the patient undertook any form of physical activity, soon after a
meal.

She had been taking lisinopril and hydrochlorothiazide for several years with good blood
pressure control, but about 6 months ago she stopped taking both medicines, because she
travelled and lived in a rural area with no pharmacy nearby, she never got the medications
refilled when she ran out. After several days she noticed that she felt just fine despite not taking
the medicines. Consequently, she never resumed them and has not seen her provider since.

PMH

HTN × 9 years

Gastroesophageal reflux × 11 years

FH

Both parents had HTN. Father had a heart attack in his early 50s and died in his late 60s of a
second heart attack; mother died a few years later from a stroke. Two brothers, 59 and 62 years
old, are both alive; the elder has HTN and hypercholesterolemia and underwent CABG surgery 3
years ago; the younger has no chronic diseases.

SH

Married for 30 years with four children (two boys, two girls all over 25 years of age with no
notable medical problems); She is now smoking about one pack per day and has been doing so
for about the past 10 years. She denies ever using recreational drugs. She does not exercise and
leads a rather sedentary lifestyle. Income is average middle class. She has good health insurance
through her husband’s employer.

Meds

Famotidine 40 mg PO once daily in the evening (over the counter);

Lisinopril/hydrocholorthiazide 20/12.5 mg PO once daily—stopped approximately 6 months

ago

All
NKDA

ROS

No hearing problems. She complains of chest pain as mentioned above but denies palpitations
and dizziness. She admits to becoming short of breath more easily in the last few weeks and has
felt a loss of energy over this same time period, although she never has been very active. She
denies nausea, vomiting, or abdominal pain. She denies any swelling in her extremities or weight
gain. She denies mental status changes.

Physical Examination

Gen

The patient is appearing to be in moderate distress

VS

232/128 mm Hg left arm (manual readings performed in the emergency department).

Measurement was BP of 236/134 mm Hg.

′″
P 74, RR 24, T 36.8°C; Wt 80 kg, Ht 5 5

Skin

Normal tone and temperature, good turgor

HEENT

funduscopic exam revealed arterial tortuosity with A/V nicking, xanthelasma on the upper
eyelids, arcus senilis around the cornea.

Neck/Lymph Nodes

Neck supple, no JVD, no bruits, no thyromegaly, or lymphadenopathy. Acanthosis nigricans seen

over the nape of neck.

Chest : CTA

CV

RRR, no murmurs or rubs appreciated; +S4 heard at apex

Abd

Soft, NT/ND, no guarding, (+) BS, no abdominal bruits appreciated, liver span about 12 cm

Genit/Rect

Normal female genitalia, heme-negative stool

MS/Ext

Normal ROM, pulses 2+ radial; 1+ to 2+ in the rest of her upper and lower extremities
Neuro

A & O × 3, CN II–XII intact, motor/sensory normal, DTRs 2+

Labs:

AST: 27 IU/

ALT: 25IU/L

Total Cholesterol: 250mg/dL

HDL: 42 mg/dL

LDL: 175 mg/dl

TG: 170 mg/dL

Troponin-I Normal

UA

Specific gravity 1.010; pH 5.8; negative for blood or protein; negative for recreational drugs

Chest X-Ray

No infiltrates

ECG

Normal sinus rhythm; LVH by voltage criteria. No old ECGs are available for comparison.

ECG showing S-T segment depression with T wave inversion in the lateral chest leads(V5-V6)

1. Design an appropriate SOAP analysis

2. Calculate BMI & CrCl

Hint: This patient problem list should have 2 active problems