Age: 34.0
Sex: M
Vaccine: SMALL
Symptoms: Angiogram pulmonary normal, Blood creatine phosphokinase MB increased, Blood creatine phosphokinase increased, Blood phosphorus increased, Brain natriuretic peptide increased
Clinical narrative: On 29 Sep, as patient was climbing stairs to go to his office, he experienced the onset of shortness of breath, which was not normal for him and was described as being "difficult to catch my breath". After about 30 minutes without resolution of his shortness of breath, patient sought evaluation at medical clinic. While in the emergency room (ER), in addition to shortness of breath, patient reported "tightness" on the left side of his chest, with an intensity level rated as 2/10 using pain scale of 0 (=no pain) to 10 (=worst pain ever experienced). Patient was not sure if this discomfort radiated to his left shoulder, because he was experiencing bilateral shoulder pain anyway. Taking deep breaths made his chest feel "tighter". He denied any nausea or vomiting or diaphoresis. His physical exam in the ER was normal except for a tachycardic pulse. Patient was initially evaluated for a possible pulmonary embolus (PE) with chest CT, which showed no evidence of PE. His CXR showed no evidence of acute pulmonary disease process. Patient's cardiac enzymes, CRP, ESR, and BNP were elevated. As his lab results became available, patient was given an aspirin and he thinks he also received morphine. He does not recall a specific change in his symptoms after receipt of these medications, but he does recall while he in the ER over several hours, the character of his discomfort changed from "tightness" to "squeezing"-type discomfort, but remained an intensity level of about 2/10. In the evening of 29 Sep 2015, patient was admitted to ICU for observation. Prior to his transfer from the ER, he received an injection of ketorolac, which relieved all of his discomfort. During the course of overnight observation, a 10-beat run of V-tach occurred, but patient did not experience any associated symptoms. During the night, he does report that his discomfort returned, and by the a.m. of 30 Sep, it was an intensity level of 4/10. On the morning of 30 Sep 2015, patient completed an echocardiogram which was normal except for mild mitral regurgitation. Later on 30 Sep 2015, patient was transported to another facility for an outpatient Cardiology evaluation, which included an echocardiogram, a heart CT, and a 24-hour Holter monitor. While there, he was prescribed and instructed on use of sublingual nitroglycerin. Patient returned home on evening of 30 Sep while wearing 24-hour Holter monitor, which he returned to clinic on 31 Sep 2015. (Interpretation report of Holter monitor is not visible, but patient reports he had a 14-beat run of ventricular tachycardia, without associated symptoms.) While at clinic, after the Holter monitor recording was reviewed, patient was seen by a Cardiology Electrophysiology Specialist. However, due to a language barrier, even with a translator, the results of the test and recommendations were not clear. Patient believes he will return for a repeat Holter monitor and evaluation in 3 months. Patient was told he could engage in activity as tolerated. He lives on the 3rd floor of his building so stair climbing is his most rigorous activity, He experiences  mild shortness of breath, but no associated chest discomfort, while climbing stairs. Pt had a follow up evaluation in Internal Medicine on 7 Oct 2015. He reported he is still experiencing shortness of breath and occasional "twinge" in his chest. No orthopnea or PND. No lower extremity edema. Patient has been placed on limited duty. On 14 Oct 2014, during telephone interaction, patient continued to report random episodes of "twinges" and mild shortness of breath when climbing stairs. He describes the twinges as brief (approximately 30 seconds) episodes of squeezing-type discomfort on the left side of his chest. He is not taking any anti-inflammatories. His next follow up appointment is scheduled for 18 Oct 2015.