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An 86-year-old white male presents to the emergency room with complaints of chest pain and shortness of breath. He reports a crushing sensation in the center of his chest that began suddenly, radiating to the chin, and accompanied by malaise, nausea, and dyspnea. The pain has persisted for two hours and is not relieved by ibuprofen. His medical history includes hypertension, a myocardial infarction, rheumatic fever, and heart valve issues. Vital signs show elevated heart rate and blood pressure. Additional evaluations are required for comprehensive management.
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Subjective • CC: 86 year old white male presents to ER with c/o chest pain and shortness of breath • HPI: crushing pain in center of chest for two hours, began suddenly with no obvious stimulus, radiates to chin; not relieved by ibuprofen; accompanied by malaise, nausea, and dyspnea
+Chest pain +HTN +Palpitations +DOE -Orthopnea -Paroxysmal Nocturnal Dyspnea +Hx of MI -Rheumatic fever +Heart murmur -Valve problems Last ECG 06/2004 Other heart tests – stress, echo, etc. +Claudication +Peripheral/dependent edema -Varicose veins -Thrombophlebitis +Cool extremities +Loss of leg/toe hair +Discoloration of extremities -Ulcers Cardiovascular ROS
Vital Signs • TPR: 97.5 degrees F, 105 bpm, 28 rpm • BP 146/92 • Pain 9/10
