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General Patient Information:
Source: Daughter, reliable
Marital Status: Married.
Occupation: Retired Nurse
Primary Language: English and Spanish
Presenting Complaint:
Substernal, toothache-like chest pain with duration of 12 hours.
History of Presenting Illness:
83 years old Caucasian retired nurse presented in the ER with chest pain. She has a chronic history of hypertension formerly controlled on diuretic monotherapy. She was admitted in the hospital with the same complaint few years ago as well. The EKG showed first degree heart block with pulmonary congestion evident on the chest roentgenogram. Cardiomegaly was also noted on the x-ray. Although, myocardial infarction was ruled out by measuring cardiac enzymes which were in normal limits. She was the discharged after administering furosemide, digoxin and enalapril.
She is post menopausal and denies having diabetes, elevated serum cholesterol or tobacco smoking. After her first admission, she takes two pillows to relieve her symptoms of orthopnea, gets dyspneic on exertion and experiences ankle edema on and off.
She was in her usual state of health till 12 in the midnight when she noted the onset of chest pain which she describes as under her breast bone. She was watching television when the pain started. The pain was throbbing, non radiating, exacerbated on exertion, relieved by rest and sudden. There were no other symptoms. She took antacid but the pain did not subside. She managed to sleep but after waking up and walking to the bathroom, the pain returned with extreme severity. It was at this point when her daughter gave her aspirin and brought her to the ER. The ER EKG showed sinus tachycardia with marked ST elevation and frequent premature ventricular contractions. The patient was immediately started on thrombolytic therapy and cardiac medications along with transfer to the intensive care unit.
Past Medical History:
She is generally very good.
Infectious disease: Routine illnesses during childhood. History negative for rheumatic fever.
Immunizations: Fully immunized
Allergies: Penicillin allergy. Discovered 20 years ago with development of generalized rash.
No history of blood transfusion.
Her surgical history is also non-significant.
Family History:
She was brought up by her uncle because both her parents died in a car accident. Her spouse is also deceased 10 years ago of pneumonia. She is the only child and her elder sister died during childbirth.
She has 3 daughters aged 66, 55 and 45 and they are all healthy. She is happy and contented and lives off of pension and old-age welfare.
Systemic Review:
HEENT: There is no complaint of headache.
She wears glasses for reading and feels her vision is deteriorating. No double vision.
Her hearing has been decreased and she wears an aid.
No epistaxis or blockade of nose. No history of tonsillitis.
RESPIRATORY:
No active complaint.
CARDIAC:
Refer to HPI.
VASCULAR:
No active complaint besides venous stasis dermal changes.
GASTROINTESTINAL:
No active complaint. She occasionally feels heartburn for that, she takes omeprazole and antacids.
GENITOURINARY:
History of recurrent urinary tract infection (UTI). She was on a continuous dose of nitrofurantoin mg OD for three months. Three pregnancies with 3 normal live births.
MUSCULOSKELETAL:
Osteoarthritis of both knees for more than 10 years. She takes ibuprofen for knee pain as and when needed.
EMOTIONAL:
She denies being depressed or anxious
References
American College of Sports Medicine,. (2016). Caffeine and Exercise Performance. Retrieved 7 February 2016, from http://www.acsm.org/docs/current-comments/caffeineandexercise.pdf
Christopher, G., Sutherland, D., & Smith, A. (2005). Effects of caffeine in non‐withdrawn volunteers. Human Psychopharmacology: Clinical and Experimental, 20(1), 47-53
