Identifying Data:
Full Name: Mrs R
Address: Not Disclosed
Age: 44 years
Date & time:9/13/2021 7:52 PM
Location: Metropolitan ED
Religion: Not disclosed
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Mode of Transport: Self
Chief Complaint: “chest pain” x1 day
History of Present Illness:
44 year old F with past medical history myopericarditis & anemia presents to ED complaining of chest pain x1 day. Patient reports R sided chest pain began suddenly yesterday evening when she was at home. Pain described as sharp, intermittent, mid-sternal, radiates to L shoulder and neck, worse with exertion. Pain feels similar to past episode in 2019 when she was diagnosed with myopericarditis. Tried Tylenol at home with minimal relief. No recent illnesses or sick contacts.
Denies fever, chills, SOB, cough, rashes, sore throat, rhinorrhea, palpitations, abdominal pain, nausea, vomiting, diarrhea, constipation, dysuria, hematuria,
Past Medical History:
Myopericarditis – 8/2019
Anemia
Past Surgical History:
Denies surgical history
Medications:
Ferrous sulfate 325 mg PO twice daily
Denies recent changes in medications
No vitamins, herbal teas or supplements
Allergies:
NKDA
No known environmental allergies
No known food allergies, no shellfish or seafood allergies
Family History:
No pertinent family history
Social History:
Mrs R is a 44 year old female living with husband and son in an apartment. Does not drink alcohol. Does not use drugs, smoke or vape. Works as house cleaner
Travel-Denies recent travel
Sleep-Sleeps 6-7 hours per night
Review of Systems:
General-See HPI
Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.
Eyes – Denies lacrimation, erythema
Ears – Denies discharge. No hearing aids.
Nose/sinuses – Denies rhinorrhea, congestion, epistaxis
Mouth/throat – Denies sore throat, voice changes.
Neck – Denies swelling, lumps, stiffness, decreased ROM
Pulmonary system – See HPI
Cardiovascular system –See HPI
Gastrointestinal system- Denies abdominal pain, nausea, vomiting, diarrhea
Genitourinary – Denies frequency, dysuria, incontinence, nocturia, hematuria
Nervous –Denies seizures, loss of consciousness, headache, weakness, problems with walking or balance, dizziness
Musculoskeletal– Denies muscle/joint pain, deformity or swelling, redness, arthritis
Hematological system –Denies bleeding, easy bruising, lymph node enlargement, blood transfusions
Vital Signs
HR: 67 BPM, regular
BP 126/66 L arm sitting
RR: 16 breaths/minute, unlabored
Temp: 98.6 degrees F oral
O2 Sat: 99% on room air
Ht 5’7’’
Wt 180 lbs
BMI 28.2
Physical Exam:
General: Adult female, well groomed, non-toxic appearing, in no acute distress. Appears stated age.
Skin: warm & moist, good turgor. capillary refill <2 seconds throughout. No jaundice or pallor. No petechiae or rash.
Head: normocephalic, atraumatic, no signs of injury, hair average quantity and distribution
Ears – external ears symmetrical.
Eyes – symmetrical; sclera white; conjunctiva pink and moist, no discharge. EOMI, PERRLA
Nose – symmetrical. No masses, lesions, deformities, trauma or discharge. Nares patent bilaterally. Nasal mucosa pink and well hydrated. No discharge noted
Oropharync – pink, moist, well hydrated. No masses, lesions noted. No leukoplakia. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions
Neck –no palpable adenopathy.
Thyroid – Non-tender; no palpable masses; no thyromegaly
Chest – Symmetrical, no deformities, no evidence trauma. No rash, skin breakdown, abrasion, ecchymosis, swelling. No breast discharge. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. No nasal flaring or retractions
Lungs – Clear to auscultation bilaterally, no adventitious sounds, wheezes or rhonchi.
Heart: RRR. S1 and S2 are distinct with no murmurs, S3 or S4. No friction rubs appreciated.
Abdomen: Bowel sounds normoactive throughout. Abdomen soft throughout, nondistended, nontender, no CVA tenderness, no bruits
Musculoskeletal: No tenderness, normal range of motion, no edema, peripheral pulses 2+, cap refill <2
Neuro: Alert, no focal deficit noted.
Assessment:
44 year old F with past medical history myopericarditis & thrombocytopenia presents to ED complaining of chest pain x1 day. Exam benign, lungs clear, heart with regular rate no murmurs, no rashes/skin changes
Plan:
r/o ACS vs recurrence myopericarditis vs GI vs herpes zoster
a. Analgesia – Ibuprofen 800 mg PO
i. Pregnancy – negative
b. CXR – No evidence of acute disease
c. ECG – Sinus rhythm, no ST changes
d. CBC – WNL
e. Troponin – WNL
f. Coagulation panel – WNL
g. BMP – WNL
h. UA – WNL
i. Patient status improved after analgesia, labs and imaging reviewed no acute intervention required. Results discussed with patient, patient feels well and agrees with discharge.
j. Patient advised to follow up with PCP within 2 days for outpatient follow up
k. Patient advised to follow up to ED if pain or symptoms worsen

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