Age: 76.0
Sex: M
Vaccine: COVID19
Symptoms: Pain, Troponin
Clinical narrative: Chief Complaint   Pt states he bagan feeling a burning sensation yestersay afternoon that subside and returned this morning at around 0330. Pt rates the pain a 6/10.  History Of Present Illness:     Patient is here with complaints of a burning sensation to the left side of his chest.  Patient stated that he has had it off and on for the past few months but today it was lingering a little bit longer than normal.  It does not get worse with activity.  He is able to reproduce the pain by pushing on a spot just about an inch to the left of his open heart surgery incision.  He denies any cough or cold-like symptoms.  Denies any fevers.  Denies any increase in swelling in any of his extremities.  Did have open heart surgery 2 years ago.  He denies any nausea vomiting or sweating.  Review of Systems:     Constitutional: No fevers, chills, sweats, weakness, or fatigue  Eye: No recent visual problems  ENT: No ear pain, no ear drainage, nasal congestion, or sore throat  Respiratory: No shortness of breath, no cough, no wheezing  Cardiovascular: Left sided Chest pain, no palpitations, or syncope  Gastrointestinal: No nausea, vomiting, diarrhea, abdominal pain, or abdominal distention  Genitourinary: No hematuria, no dysuria, no frequency, no flank pain, no incontinence  Integumentary: No rash, pruritus, or abrasions  Neurologic: Alert & oriented X 4, no headache, no dizziness, no numbness or tingling  Physical Exam  Vitals & Measurements  T: 36.5  °C (Oral)  HR: 69(Monitored)  RR: 13  BP: 122/70  SpO2: 92%  HT: 178.000 cm  HT: 178.000 cm  WT: 95.000 kg  WT: 95.000 kg  BMI: 29.980  O2 Therapy: Room air      General: Alert and oriented, well nourished, no acute distress.  Lungs: Clear to auscultation all lung fields, non-labored respiration.  Heart: Normal rate, regular rhythm, no murmur, gallop or edema.  Abdomen: Soft, non-tender, non-distended, normal bowel sounds, no masses.  Musculoskeletal: Reproducible pain to left side of chest.  Skin: Skin is warm, dry and pink, no rashes or lesions.  Neurologic: Awake, alert and oriented X4.  Psychiatric: Cooperative, appropriate mood and affect.     Medical Decision Making:     DDx: All differentials considered.  Assessment/Plan        1. Chest wall pain   The patient is not ill-appearing or toxic upon arrival to the emergency room.  I was able to reproduce his left-sided chest pain with palpation just about an inch to the left of his sternum/incisional site.  He has no other acute findings on physical exam.  His labs come back unremarkable.  His EKG is unchanged from his previous EKGs.  His initial troponin was negative.  We did discuss doing trending troponins but the patient did not feel that it was necessary at this time.  Patient will be discharged at this time with strict return precautions.  He denies any further concerns.   Orders:   Cardiac Monitoring, 01/06/22 10:51:00 CST, Constant Order  EKG, 01/06/22 10:51:00 CST, Stat, Once, Stop Date 01/06/22 10:51:00 CST, Walk, No, No, Standard Precautions, chest pain  Saline Lock Insert, 01/06/22 10:51:00 CST, Once  XR Chest 1 View, 01/06/22 10:51:00 CST, Stat, 01/06/22 10:51:00 CST, Chest Pain, No, Transport Mode: Walk, , No, , No, Rad Type       Patient Education   Nonspecific Chest Pain, Adult, Easy-to-Read  Follow Up        With  When  Contact Information         Additional Instructions: Please follow-up with your primary care provider as needed.  Take your medications as prescribed.  Return to the emergency room with any worsening symptoms or concerns such as: Worsening chest pain, shortness of breath, breaking out into a cold sweat, fevers greater than 101 or any worsening symptoms or concerns.