Mr. Harvey Mason is a 50-year-old gentleman who comes in complaining of chest pressure, shortness of breath and fatigue.
The pain began 2 hours ago when he awoke in the morning. The pain is substernal and radiates to the right shoulder. It has been coming and going for the last 3 months. Previously the pain resolved with rest for a few minutes, but now is not going away. Pain is exacerbated with activity, no alleviating factors. He has had some nausea but no vomiting. He reports no unusual activity today; he had a busy day yesterday at work. Today he awoke with the pain, so he took his medicine and started getting ready for work. When the pain was unrelieved, he decided to get evaluated.
Married, has 2 grown children. He works for UPS during the daytime and as an Uber driver during his off hours. He doesn’t get much exercise, just helping people with their luggage in and out of the trunk. Mostly eats fast food while in his car. No smoking or alcohol use. No illicit drug use.
Review of systems:
No sweating, fever, chills, vomiting or diarrhea. No abdominal pain or back pain. No changes with voiding or bowel movements. No skin changes. He has gained 10 pounds in the last year.
Gen: Awake and alert, appears uncomfortable and mildly diaphoretic.
HEENT: NCAT. Oropharynx without erythema or exudate.
CV: Regular rate and rhythm. Possibe S3 present. No murmurs, rubs or gallops. No JVD.
Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended. Positive bowel sounds in all four quadrants. No epigastric tenderness
Extremities: No edema bilaterally. He has equal pulses in the radial arteries bilaterally.
MSK: Normal shoulder range of motion. No tenderness to palpation over the sternocostal margins.