Reference no: EM133218496

HPI:

A 56-year-old man is brought to the emergency department (ED) complaining of a chest discomfort for about 90 minutes. He has had occasional symptoms for a month, but it is worse today.

1. What history questions will you ask specific to the chief complaint?

 Today's symptoms began while he was walking his dog and decreased slightly with rest, but have not resolved. He describes the feeling as a pressure sensation in the left substernal area of his chest associated with shortness of breath and mild diaphoresis. He does not have any radiation of the discomfort today, but has experienced radiation to the left upper extremity in the past. The patient denies any health problems, but his wife reports that he has not seen a physician in years. His wife made him come in because his younger brother had a heart attack 6 months ago. He is a vice president of a bank and lives with his wife and three daughters.

1. What will you focus your physical examination on? What specific tests will you assess?

On physical examination, he is an anxious, obese, gentleman who appear pale and has a moist brow. His temperature is 98.8 ºF (37.1 ºC), pulse is 105 beats/min, respirations is 18 breaths/min, blood pressure is 190/95 mm Hg, height is 74 in, and weight is 250 lb. Cardiac examination reveals regular rhythm without murmur, but he has an S4 gallop. Lungs are clear to auscultation. Neck is without carotid bruits or jugular venous distension. Abdomen is normal. He does have a right femoral bruit. Extremities reveal trace edema but no clubbing cyanosis. He has 2+ pulses in radial and dorsal pedalis arteries. Rectal examination had no masses or tenderness with a normal prostate and is guaiac negative.

1. What is your most likely diagnosis? 
2. What is your next diagnostic step? 
3. What is the next step in therapy?
4. What education will you provide to the patient and his wife?
5. What will you focus you physical examination on? What specific tests will you assess?

He denies having fever, chest pain, peripheral edema, or other symptoms.