Clinical note · #34
Office & outpatient
Patient: James Anderson
Age: 68
Place of Service: Office – Outpatient
Patient Status: New Patient
Chief Complaint: Worsening shortness of breath and chest discomfort.
History of Present Illness (HPI):
The patient is a 68-year-old male presenting for evaluation of progressively worsening shortness of breath and intermittent chest discomfort over the past three days. Symptoms began abruptly and have worsened despite rest. He reports dyspnea at rest and with minimal exertion, associated with orthopnea and new bilateral lower-extremity swelling.
He also reports intermittent chest pressure described as a tight sensation lasting several minutes, associated with diaphoresis and nausea. He reports lightheadedness but denies syncope. Symptoms have significantly limited his ability to perform routine daily activities.
The patient has a history of coronary artery disease and chronic systolic heart failure. He reports recent noncompliance with diuretic therapy due to running out of medication. Given the severity and progression of symptoms, there is concern for acute decompensated heart failure versus acute coronary syndrome.
Review of Systems (ROS):
- Cardiovascular: Chest pressure, orthopnea, leg swelling
- Respiratory: Shortness of breath at rest and with exertion
- Constitutional: Fatigue, diaphoresis
- Gastrointestinal: Nausea
- All other systems reviewed and negative
Past Medical History:
- Coronary artery disease
- Chronic systolic heart failure
- Hypertension
- Hyperlipidemia
Medications:
- Furosemide (recent noncompliance)
- Metoprolol
- Atorvastatin
- Lisinopril
Allergies: No known drug allergies
Physical Examination:
- General: Appears ill and uncomfortable
- Vital Signs: BP 162/94 mmHg, HR 108 bpm, RR 24/min, SpO₂ 92% RA
- Cardiovascular: Tachycardia with S3 gallop
- Lungs: Bibasilar crackles
- Extremities: 2+ bilateral pitting edema
Diagnostic Data:
- EKG ordered and independently interpreted – sinus tachycardia with nonspecific ST-T changes
- Chest X-ray ordered and reviewed – pulmonary congestion noted
- Laboratory tests ordered – BMP, BNP, troponin
Assessment:
- Acute decompensated systolic heart failure
- Chest pain concerning for acute coronary syndrome
Plan:
- Immediate discussion with cardiology
- Decision made for hospital admission
- Aspirin administered in office
- Oxygen initiated
- EMS activated for transport to the emergency department