FM H&P 1

Chief Complaint: “Stabbing Chest pain” x 2 weeks

History of Present Illness:

34 y/o male that presents with left sided chest pain for the past two weeks. The pain is persistent and it is stabbing in nature. He describes the pain as constant throughout the day but notes exacerbations of severe intensity, reaching 10/10 in severity. These episodes last only a few seconds. Baseline pain level remains at 6/10. Patient has attempted to alleviate the discomfort with Tylenol but notes that it does not help. He reports no specific triggers for the exacerbations. Patient states there is no radiation of pain. Denies SOB, cough, orthopnea, dyspnea of exertion, pleuritic pain, palpitations or syncopal episodes.

Past Medical History:

  • No past medical history

Past Surgical History:

  • No past surgical history

Medications:

  • No medications
  • No herbal supplement use

Allergies:

  • No known drug allergies
  • No known food allergies
  • No known environmental allergies

Family History:

  • Mother: Age 60, alive, no significant pmhx.
  • Father: Age 63, alive with pmh of HTN
  • Maternal grandparents: unknown
  • Paternal grandparents: unknown

Social History:

  • Smoking: non-smoker
  • Substance use: Socially drinks alcohol,1-2 drinks twice a month.
  • Caffeine: Admits to caffeine use, 1 cup of coffee per day
  • Occupational history: Gym trainer
  • Home situation:Lives with girlfriend in apartment building.

Review of Systems:

  • General: Denies generalized weakness/fatigue, fever, chills, night sweats, weight loss or gain, changes in appetite.
  • Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, changes in hair distribution.
  • Head: Denies head trauma, vertigo.
  • Eyes: Denies ear pain, deafness, discharge, tinnitus.
  • Ears: Denies deafness, ear pain, discharge, tinnitus.
  • Nose: Denies epistaxis, discharge, congestion
  • Mouth/throat: Denies sore throat, voice changes, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies lumps, nipple discharge, pain.
  • Pulmonary: Denies cough, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Admits to chest pain. Denies edema/swelling of ankles or feet, hx of HTN, palpitations, irregular heartbeat, syncope, known heart murmur.
  • Gastrointestinal: Denies change in appetite, intolerance to specific foods, abdominal pain nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
  • Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
  • Sexual History: Admits to currently being sexually active with 1 female partner. Admits to condom use. Denies history of STIs.
  • Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
  • Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric: Denies depression/sadness, anxiety, OCD, or ever seeing a mental health professional.

Physical Exam: 

Vitals:

  • BP: 119/78(seated,left arm)  Right 125/74(seated, right arm)
  • HR: 65 BPM (regular)
  • RR: 16/min (unlabored)
  • T: 97.5 F (oral)
  • O2: 98% (room air)
  • Height: 72in Weight: 170lbs BMI: 23.1

General: AAO x 3, appears in no acute distress, well groomed, appears stated age

Skin: Warm & moist; good turgor; non-icteric; no rashes or lesions noted

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Symmetrical OU. No strabismus, exophthalmos, or ptosis. Sclera white, cornea clear, conjunctiva pink.

Ears: Symmetrical and appropriate in size. No lesions, masses or trauma on external ears. No discharge or foreign bodies on external auditory canals.TM pearly grey and intact with light reflect in good position 

Nose: Symmetrical. No masses, lesions, deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated

Sinus: Non-tender to palpation.

Mouth/pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.

Neck: Trachea midline. Supple and nontender to palpation. No cervical adenopathy noted.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.

Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.

Lungs: Clear to auscultation bilaterally.

Abdomen: Abdomen flat and symmetric, no scars, striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Tympanic throughout, nontender, no guarding or rebound noted. Negative CVA tenderness.

Nervous system: Cranial nerves I-XII intact.

Peripheral vascular: Pulses 2+ bilaterally in upper and lower extremities. No clubbing, cyanosis or edema noted.

Musculoskeletal: Tenderness to palpation over the second and third costosternal junctions. FROM (full range of motion) of all upper and lower extremities bilaterally. Non tender to palpation.

Rectal: exam not performed. 

Differential Diagnosis:

 Costochondritis: Seeing that the patient’s chest pain was reproduced upon palpation, the most likely diagnosis would be costochondritis.Costochondritis is acute inflammation of costal cartilages or costochondral junction. The etiology is often idiopathic but could occur postviral or posttraumatic.My patient works as a gym trainer so the physical strain from work could have led to the onset of his symptoms.

Tietze Syndrome:Noting that there was chest wall tenderness upon palpation, tietze syndrome is another differential that comes to mind. It most commonly involves the second and third costco chondral junctions. This can also occur due to physical strain, but is differentiated from costochondritis because there would be palpable edema with the reproduced chest wall tenderness. They also can complain of pleuritic chest pain, which my patient denied, making this less likely.

GERD: Acid reflux can sometimes cause chest pain, noting the patient’s age is a common diagnosis that can present with chest pain if not treated. However the stabbing nature and the severity of the pain may not fit the typical GERD symptoms. With the physical exam findings, we were able to rule this out.

EKG

  • Normal sinus rhythm 

Assessment:

 34 year old male with no significant medical history presents with stabbing left sided chest pain x2 weeks. Patient has no associated symptoms. Upon examination, the patient was tender over the second and third costosternal junctions. There are no labs to review at this point. Ekg showed normal sinus rhythm. The diagnosis is most consistent with costochondritis. 

Plan: 

Costochondritis 

  1. Ibuprofen 600 mg every 6 hours as needed 
  2. Avoid strenuous activity that may exacerbate the chest pain (heavy lifting)
  3. Apply warm compress over area 15-20 minutes to help alleviate discomfort
  4. Follow up in 1 week to see if symptom relief. Referral to Cardiology if no relief .