2-6 PATIENT NOTE: CHEST PAIN HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 62 YO M C/O CHEST PAIN THAT BEGAN AT 4 AM WHILE HE WAS ASLEEP. HOUR AGO, MIDCLAVICULAR LEFT SIDED , 8/10, SHARP. GETTING WORSE. NO AGGRAVATING OR ALLEVIATING FACTOR. CONSTANT PAIN SINCE 4 AM. PATIENT REPORTS SHORTNESS OF BREATH, VOMITED ONCE CLEAR FLUID AND INCREASED DIAPHORESIS. ROS: STOMACH ULCER CONTROLLED BY DIET ALLERGIES: NONE MEDICATIONS: ASPIRIN, WATER PILL, MAALOX PMH: DIANOSED WITH LCER 1 YEAR AGO PSH: KNEE REPLACEMENT 10 YEARS AGO FH: MOTHER DECEASED FROM LUNG CANCER, FATHER ALIVE WITH GERD SH: SMOKED 2-4 PPD FOR 25 YEARS NOW SMOKES 1PPD, DRINK ALCHOL EVERYDAY CAGE . USES COCAINE AND MARIJUANA LAST USE ONE YEAR AGO. WORKS AS PAROLE OFFICE, SEXUALLY ACTIVE WITH WIFE ONLY. PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. PHYSICAL EXAM: HE IS IN ACUTE DISTRESS AND HIS VITALS ARE WITHIN NORMAL LIMITS. HIS HEAD, EYES, NOSE APPEAR NORMAL WITHOUT ABNORMALITIES. HIS NECK IS SUPPLE WITH NO LYMPHADENOPATHY. HIS THYROID IS WITHIN NORMAL LIMITS. THERE WAS NO JUGULAR VENOUS DISTENSION OR CAROTID BRUITS NOTED. HIS BREATH SOUNDS WERE CLEAR BILATERALLY. HIS HEART SOUNDS WERE NORMAL WITH NO RUBS, GALLOPS. MURMURS. HIS POINT OF MAXIMAL IMPULSE WAS NOT DISPLACED. HIS ABDOMEN IS SOFT, NONTENDER, NONDISTENDED AND HAS NORMAL BOWEL SOUNDS. THERE WAS NO EDEMA OF THE EXTREMITIES WITH NORMAL AND SYMMETRIC PULSES BILATERALLY. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. Diagnosis #1: PERICARDITIS

HISTORY FINDING(S) - C/o chest pain while he was asleep - Sharp pain with 8/10 in intensity - C/o Short of breath, increasing diaphoresis H/o cocaine and marijuana use Diagnosis #2: MYOCARDIAL INFARCTION

PHYSICAL EXAM FINDING(S) - Patient is in acute distress - Normal S1/S2, RRR - PMI not displaced

HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - C/o mid-clavicular left sided chest pain - Patient is in acute distress - Sharp pain with 8/10 in intensity and - No gallops, murmurs, rubs, getting worse Normal S1/S2 -C/o shortness of breath, increasing diaphoresis H/o cocaine and marijuana use - PMI not displaced Diagnosis #3: CHOSTOCHONDRITIS HISTORY FINDING(S) - Sharp chest pain with 8/10 intensity and getting worse - Constant pain since 4 AM - Pain is in the mid-clavicular area Diagnostic Studies: - EKG - CBC/UA - CPK, CPK-MB, TROPONIN - CT CHEST - CXR PHYSICAL EXAM FINDING(S) - Patient is in acute distress - RRR, Normal S1/S2, No rubs, gallops, murmurs