Hypertrophic Cardiomyopathy: A Case Study
Chief complaint is chest pain.
HISTORY OF PRESENT ILLNESS
Ms. [Name] is a 49-year-old female who has a history of hypertrophic cardiomyopathy with an _____ in place, and also has a history of atrial fibrillation. She comes to the emergency department today complaining of chest discomfort. It began 3 days ago and has been constant and persistent since then. The pain is located on center and left side of her chest. It is associated with some shortness of breathe. The pain feels like tightness. She is not having any associated fever, chills, nausea, vomiting, diarrhea, lower extremity edema or pain.
All other systems are reviewed and are negative.
Past medical history is notable for the hypertrophic cardiomyopathy, AICD, atrial fibrillation, …show more content…
Abdomen is soft, nontender, nondistended, with good bowel sounds.
Extremities: No cyanosis, clubbing, edema. Pulses 2+ and equal bilaterally in the wrists, and ankles.
Skin: Warm and dry with no lesions.
MEDICAL DECISION MAKING
EKG was obtained immediately on Ms. [Name]'s arrival. It shows her to be in a sinus tachycardia with a rate of 130 beats per minute. She has a right axis. She has evidence of a right bundle branch block. This EKG was repeated and verified to be the same. On comparison with old EKG's, there is no change. However, her most recent EKG from November 9, shows the patient to be in a normal sinus rhythm with a rate of 55 beats per minute. At that time she had a left axis deviation. However, her previous EKG's in the emergency department all show this right axis, so there is no significant abnormality that is new in the EKG today.
I am currently giving the patient aspirin, nitroglycerin, and Dilaudid for pain.
I am awaiting her laboratory studies including D-dimer, cardiac enzymes.
Final documentation will be made after the results of those studies are known, and after I see how she responds to the pain medications and
HISTORY OF PRESENT ILLNESS
Ms. [Name] is a 49-year-old female who has a history of hypertrophic cardiomyopathy with an _____ in place, and also has a history of atrial fibrillation. She comes to the emergency department today complaining of chest discomfort. It began 3 days ago and has been constant and persistent since then. The pain is located on center and left side of her chest. It is associated with some shortness of breathe. The pain feels like tightness. She is not having any associated fever, chills, nausea, vomiting, diarrhea, lower extremity edema or pain.
All other systems are reviewed and are negative.
Past medical history is notable for the hypertrophic cardiomyopathy, AICD, atrial fibrillation, …show more content…
Abdomen is soft, nontender, nondistended, with good bowel sounds.
Extremities: No cyanosis, clubbing, edema. Pulses 2+ and equal bilaterally in the wrists, and ankles.
Skin: Warm and dry with no lesions.
MEDICAL DECISION MAKING
EKG was obtained immediately on Ms. [Name]'s arrival. It shows her to be in a sinus tachycardia with a rate of 130 beats per minute. She has a right axis. She has evidence of a right bundle branch block. This EKG was repeated and verified to be the same. On comparison with old EKG's, there is no change. However, her most recent EKG from November 9, shows the patient to be in a normal sinus rhythm with a rate of 55 beats per minute. At that time she had a left axis deviation. However, her previous EKG's in the emergency department all show this right axis, so there is no significant abnormality that is new in the EKG today.
I am currently giving the patient aspirin, nitroglycerin, and Dilaudid for pain.
I am awaiting her laboratory studies including D-dimer, cardiac enzymes.
Final documentation will be made after the results of those studies are known, and after I see how she responds to the pain medications and