Problem
A. A 69-year-old male is brought to the cardiac intensive care unit from the emergency department with a recent onset of "pain in the front part of my chest."
B. The patient reports a past medical history of Marfan syndrome and hypertension. He states that he was working in his yard when he experienced a sudden, tearing sensation in his anterior chest lasting approximately 10 to 15 seconds. His chest pain has been a constant ache that he rates as an 8 out of 10. The pain radiates from the anterior to the posterior aspect of his chest. He reports new onset of shortness of breath and diaphoresis.
C. He denies loss of consciousness, nausea, vomiting, and pain or numbness in his extremities.
D. He has a history of HTN and takes his Lisinopril daily. He denies a history of coronary artery disease or use of illicit substances.
Review of Systems (ROS)
A. Constitutional: Denies weakness, fatigue, night sweats, and unintentional weight loss.
B. Cardiovascular: shortness of breath and chest pain is exacerbated by activity. Symptoms are mildly alleviated by rest. Denies history of palpitations, orthopnea, heart murmurs, and lower extremity edema. No history of claudication or thrombophlebitis.
C. Pulmonary: shortness of breath is exacerbated by activity and partially alleviated by rest. Denies wheezing, hemoptysis, and cough.
D. Gastrointestinal: Denies constipation, diarrhea, melena, hematochezia, and vomiting.
E. Genitourinary: Denies history of frequency, dysuria, hesitancy, urgency, polyuria, nocturia, hematuria, or incontinence.
F. Musculoskeletal: Denies history of muscle myalgia, recent trauma or injury, joint pain, swelling, stiffness, or erythema.
G. Neurological: Denies history of seizures, syncope, numbness, tingling, extremity weakness, or changes in speech. No headaches, memory changes, or forgetfulness.
H. Psychiatric: Denies history of depression, anxiety, and other previous psychiatric diagnoses.
I. Hematologic/lymphatic/immunologic: Denies history of fever, chills, easy bruising, bleeding, or enlarged/tender lymph nodes.
Physical Exam reveals
A. Vital signs: temperature 98.2° F oral; HR 113 ; respirations 24/min; bp 158/94 mm Hg;
B. Constitutional: . He is well groomed and is alert, cooperative,
C. Cardiovascular: Heart rhythm is regular. S1 and S2 present; no S3 or S4 noted. Diastolic murmur (IV/VI) auscultated at the right sternal border, second intercostal space. No rubs, clicks, or gallops. No heaves, thrills, or lifts noted upon palpation. Bilateral lower extremity edema (1+). No aortic, renal, iliac, or femoral bruits noted.
D. Pulmonary: Regular respiratory rate and rhythm. No use of accessory muscles. Trachea midline. Chest wall expansion symmetrical bilaterally. Breath sounds clear bilaterally in all lung fields. No wheezes, rhonchi, or crackles noted.
E. Gastrointestinal: No abdominal distention, pulsations, heaves, or masses noted. Bowel sounds normoactive in all four quadrants. Tympany heard with percussion in all quadrants. No rebound tenderness or guarding noted. Liver not palpable.
F. Renal/Genitourinary: No costovertebral angle tenderness.
G. Musculoskeletal: Skeletal frame consistent with previous diagnosis of Marfan syndrome. Muscle tone equal bilaterally with no masses or tenderness noted upon palpation.
H. Psychiatric: Affect and behavior appropriate for situation. The thought process is logical; speech is clear and easily understood. Demonstrates appropriate emotions and cognition.
I. Hematologic/Lymphatic/Immune: No signs of active bleeding. No petechiae, purpura, or ecchymosis noted. No enlarged or tender lymph nodes. Spleen not palpable.
Task
• What are your differentials?
• What are your next steps?
• What are the pertinent positives for this case?
• What are the significant negatives?
• What diagnostics would you order?