DISCHARGE DIAGNOSIS: Chest pain.
DISCHARGE MEDICATIONS:
1. L-thyroxine 0.075 mg p.o. daily.
2. Trilafon 4 to 8 mg p.o. q.h.s.
REASON FOR ADMISSION: Left-sided chest pain.
MEDICATIONS ON ADMISSION:
1. L-thyroxine 0.075 mg p.o. daily.
2. Trilafon 4 to 8 mg p.o. q.h.s.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with a past medical history significant for stage II colon cancer, status post a total colectomy in XXXX, hypothyroidism, depression, who presents with left-sided chest pain, which began 2 days prior to admission.
The pain began Friday while the patient was sitting at work, at rest, and lasted for a few minutes. The pain was described as a pressure that moved towards the sternum. The patient denied any shortness of breath, nausea, diaphoresis or pain radiating into his arm or jaw. The pain was relieved on its own with no medications.
Over the weekend, the patient continued to have similar episodes with the chest pain. The pain was noted to be positional in nature.
Of note, the patient did note that he drank approximately 12 beers the night prior to admission. The patient denied any similar chest pain prior to these most recent episodes. He denied any palpitations. The patient did note that he had increased pain with certain positions and movements. The patient denied any increased pain with deep inspiration or expiration.
PAST MEDICAL HISTORY:
1. Hodgkin’s disease with chemotherapy and radiation in XXXX.
2. Hypothyroidism.
3. Stage II carcinoma of the transverse colon with several colonic polyps, status post subtotal colectomy with ileosigmoid anastomosis in XXXX.
4. Depression.
SOCIAL HISTORY: The patient currently has a girlfriend. He lives with his mother. He does have 1 son who is 19 years old. The patient denies any tobacco use. He does note positive alcohol use of approximately 12 years during the weekends and approximately 3 to 4 beers per night during the week days. He denies any IV drug use. He does do some lifting for his job.
ALLERGIES: Chloromycetin causes shortness of breath and hypertension.
PHYSICAL EXAMINATION AT TIME OF DISCHARGE: Vital signs at discharge include a respiratory rate of 18 and pulse 64, temperature 97.8, oxygen saturation 98% on room air, blood pressure 122/82. In general, this is a very pleasant, alert, well-nourished and well-developed male in no acute distress sitting in his hospital room. HEENT: Pupils equal, round, and reactive and accommodation. Extraocular muscles are intact. No scleral icterus. Mucous membranes are moist. Neck: Supple, no cervical lymphadenopathy, no jugular venous distention. Heart: S1, S2 heard. No murmurs, rubs or gallops. Regular rate and rhythm. Lungs: Clear to auscultation bilaterally. No wheezing or crackles. Abdomen: Soft, nontender, nondistended, positive bowel sounds. Extremities: No lower extremity edema. Extremities are warm with positive palpable pulses. There is no calf tenderness. Musculoskeletal: There is no pain with palpation over the anterior or posterior thorax. No pain noted along the ribs with palpation. Neurologic: The patient is awake and oriented x3. No focal deficits are noted.
LABORATORY DATA AT TIME OF DISCHARGE: Troponin less than 0.03 x2, phosphorous 2.8, magnesium 2.2, sodium 138, potassium 4, chloride 107, CO2 26, BUN 10, creatinine 0.9, glucose 98. White blood cell count 7.3, hemoglobin 13.6, hematocrit 40.4.
INVESTIGATIONS:
1. Portable AP chest x-ray performed on July 5, XXXX, showed no acute cardiopulmonary disease, costophrenic angles were sharp. There were no effusions.
2. Exercise tolerance test was performed on July 6, XXXX. This was a diagnostically adequate stress test, negative for angina and electrocardiographic evidence of ischemia.
HOSPITAL COURSE: This is a (XX)-year-old male with a past medical history significant for hypothyroidism, depression, history of colonic polyps, status post colectomy in XXXX, presenting with left-sided chest pain, which was nonradiating, positive positional component. There was positive pressure described that moved towards the patient’s sternum. There was no shortness of breath, nausea, diaphoresis or pain radiating into the arm or jaw. The patient had taken no medications and the pain was relieved on its own. The patient was admitted to telemetry for rule out of acute coronary syndrome and cardiac etiology of his chest pain.
HOSPITAL COURSE BY SYSTEM:
1. Chest pain: A (XX)-year-old male presenting with a 2-day history of episodic left-sided, nonradiating chest pain, which was positional in nature. The patient was admitted to telemetry to rule out acute coronary syndrome. Cardiac enzymes were cycled until they peaked. Two cardiac enzymes were drawn and both troponins were less than 0.03. During admission, the patient was monitored on telemetry. Initial EKG that was done at the time of admission showed normal sinus rhythm at 74 with no evidence of any ST changes. The patient was given 365 mg of aspirin in the ED. The patient underwent exercise tolerance test, which was a diagnostically adequate stress test, which was negative for any signs of angina or evidence of ischemia. The patient did not have any further chest pain while in the hospital and remained stable. For the patient’s left-sided chest pain, he was given a trial of Advil 400 mg q. 8 h. p.r.n. for likely musculoskeletal nature of his pain.
2. Hypothyroidism: The patient continued on his home levothyroxine dose while in the hospital. It was recommended that the patient consider laboratory work to check his TSH as an outpatient to ensure that he is at the proper dosage.
3. Depression: The patient continued with his home does of Trilafon while in the hospital.
4. Alcohol use: The patient was monitored closely during admission for any signs of alcohol withdrawal. The patient did not have any signs of alcohol withdrawal, as it is thought that he had just binged on alcohol the night prior to admission. He remained stable and did not require any CIWA scale or Ativan.
CONDITION AT DISCHARGE: Stable.
FOLLOWUP INSTRUCTIONS: The patient is stable at discharge. The patient should follow up with his primary care physician within 1 week of discharge. It was recommended that the patient continue his previous home medications of L-thyroxine and Trilafon, which were not changed during this admission. The patient is able to return to work. The patient was not started on any new medications. The patient was notified that if he should have persistent pain that seems to worsen he should seek medical care. The patient was also told that he could continue a trial of Advil 400 mg p.o. q. 8 h. as needed for musculoskeletal pain to see if this does relieve his pain. The patient can resume his normal diet and activity as tolerated.
