History
Identifying Data:
Name: IV
Address:New York
Date of Birth: 09/08/1978
Date & Time: November 21 2022, 12:00 AM
Location: ER Metropolitan Hospital, Manhattan, NY
Sex: Male
Marital Status: Single
Nationality: Hispanic
Source of Information: Self
Reliability: Reliable
Source of Referral: Self
Chief Complaint:
“I am having chest pain and my heart is racing” x 1 hour
HPI
40 year old male patient with PMHx of asthma, presents to the ED with shortness of breath, palpitations, and midsternal chest pain x 1 hour after using cocaine at a party earlier this evening. Rates the pain as 7/10, is non radiating and describes it as sharp in nature. Denies alleviating, aggravating factors or taking any other drug/ medication. Patient is unsure of how much cocaine he took but notes he was constantly snorting cocaine over the past 3 hours before the symptoms began. Patient notes that he has not used cocaine in the last 20 years. Denies blurry vision, headache, dizziness, nausea, vomiting, abdominal pain, hematuria, lower extremity tenderness or swelling.
Past Medical History
Asthma
Past Surgical History
N/A
Medications:
N/A
Allergies:
No known food and drug allergies
Family Hx:
Father – alive and well
Mother – alive and well
Social Hx:
IV is a male who lives at home with his brother and works at an office.
Habits – Reports cocaine use but had quit for 20 years. Reports alcohol use socially.
Travel – Denies recent travel
Diet – States eat fast food more than home cooked meals.
Exercise – Denies.
Safety measures – Admits to always wearing a seat belt
Sexual Hx – Patient is sexually active with one female partner. Denies use of protection.
Review of Systems:
General – Denies loss of appetite, weakness, fatigue, weight gain/loss, or night sweats.
Skin, hair, nails – Denies changes in hair distribution in the extremities. Denies excessive dryness or sweating.
Head – Denies headaches, vertigo, unconsciousness, or head trauma.
Eyes – States wearing glasses. Denies visual disturbances, or photophobia. Last eye exam – unknown.
Ears – Denies hearing issues, pain, discharge, or tinnitus.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam – unknown
Neck – Denies localized swelling/lumps or stiffness/decreased range of motion.
Pulmonary system – Reports shortness of breath. Denies, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Reports chest pain and palpitations Denies edema/swelling of ankles, syncope or known heart murmur.
Gastrointestinal system –. Denies abdominal pain, nausea, decreased appetite, flatulence, constipation, rectal bleeding, vomiting, dysphagia, pyrosis, diarrhea, jaundice, or hemorrhoids.
Genitourinary system – Denies nocturia, polyuria, oliguria, hematuria, or dysuria.
Sexual Hx – Sexually active with one female partner. Denies condom use.
Nervous – Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength,
or change in cognition / mental status / memory.
Musculoskeletal system – Denies any inflammation, abrasions, atrophy or pain.
Peripheral vascular system – Denies peripheral edema, color changes, or varicose veins.
Hematological system – Denies bruising, blood transfusion, or lymph node enlargement.
Endocrine system – Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating.
Psychiatric – Denies depression/sadness, anxiety, suicidal ideations, or ever seeing a mental health professional.
Physical Exam
Vitals:
Blood pressure: 142/107 (right arm seated)
Temperature: 97.9 F (oral) Heart Rate: 136, regular
SpO2: 99% on RA Respiratory rate: 18 unlabored
Weight (kg): 261 lbs Height: 5’8’’ BMI: 36.68
General: A&O x 3, neatly groomed, well nourished, in moderate distress due to pain, Obese, diaphoretic
Skin: Warm, good turgor, no pigmentation, no rash, and no moles noted.
HEENT: Congestion and Rihnorrhea. No nasal septal hematoma or perforation. Atraumatic, normocephalic, well hydrated. Conjunctiva normal, PEERL, EOMI.
Pulmonary: Clear to auscultation in all fields bilaterally. Chest expansion and diaphragmatic excursion
symmetrical. Respirations unlabored/no paradoxical respirations or use of accessory muscles noted.
Cardiovascular: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdomen: Active bowel sounds in all 4 quadrants. Soft, symmetric, non-distended and non-tender. No CVA tenderness, no guarding/rebound/rigidity. No scar, mass, striae, or pulsations noted.
Musculoskeletal: No ecchymosis, edema, deformities. Full ROM in all four extremities. Strength- 5/5 both upper and lower extremities bilaterally.
Peripheral Vascular: Warm to touch bilaterally. 2+ pulses in all extremities. No ulcerations or edema. No
calf tenderness bilaterally, equal in circumference. No palpable cords bilaterally.
Neurological: A&O person/place/time. Able to follow commands. No gross sensory or motor deficits. Normal gait.
Psychiatric: Appropriate appearance, speech/language, mood, thought process/content.
Assessment and plan:
40 year old male patient with PMHx of asthma, presents to the ED with shortness of breath, palpitations, and midsternal chest pain x 1 hour after using cocaine at a party earlier this evening. Patient hypertensive to 142/102 and persistently tachycardic to 140s on cardiac monitor. Will r/o ACS in the setting of chest pain and palpitations with recent cocaine use. Obtain CBC, BMP, Mg, Troponin, CXR, EKG, and give 2 of ativan.
Differential Diagnosis
- Cocaine intoxication
- Cocaine withdrawal
- ACS
- MI
Orders
- CBC to evaluate for anemia
- BMP to evaluate for electrolyte abnormalities and anion gap acidosis
- Magnesium to evaluate for electrolyte abnormalities
- Troponin to rule out ACS
- CXR
- EKG to check for arrhythmias, rule out MI
- 2 mg Ativan for symptomatic relief
Results
EKG: Normal Sinus Rhythm, rate 100 BPM
CBC and differential
| Component | Ref Range & Units | Results | ||
| WBC | 4.30 – 11.00 x10(3)/mcL | 9.97 | ||
| RBC | 4.60 – 6.20 x10(6)/mcL | 5.75 | ||
| HGB | 14.0 – 18.0 g/dL | 15.7 | ||
| HCT | 40.0 – 54.0 % | 47.3 | ||
| MCV | 80.0 – 94.0 fL | 82.3 | ||
| MCH | 26.0 – 33.0 pg | 27.3 | ||
| MCHC | 31.0 – 36.0 g/dL | 33.2 | ||
| MPV | 8.0 – 10.5 fL | 10.5 | ||
| RDW | 12.5 – 16.5 % | 12.9 | ||
| PLT | 150 – 450 x10(3)/mcL | 286 | ||
| Neutrophil % | 50.0 – 65.0 % | 83.4 High | ||
| Lymphocyte % | 25.0 – 40.0 % | 12.2 Low | ||
| Monocyte % | 4.0 – 10.0 % | 3.0 Low | ||
| Eosinophil % | 0.0 – 5.0 % | 0.7 | ||
| Basophil % | 0.0 – 1.0 % | 0.4 | ||
| Imm Gran % | 0.0 – 2.0 % | 0.3 | ||
| Neutrophil Abs | 1.78 – 5.38 x10(3)/mcL | 8.31 High | ||
| Lymphocyte Abs | 1.32 – 3.57 x10(3)/mcL | 1.22 Low | ||
| Monocyte Abs | 0.30 – 0.83 x10(3)/mcL | 0.30 | ||
| Eosinophil Abs | 0.04 – 0.54 x10(3)/mcL | 0.07 | ||
| Basophil Abs | 0.00 – 1.00 x10(3)/mcL | 0.04 | ||
| Immature Gran Abs | 0.00 – 0.20 x10(3)/mcL | 0.03 | ||
| NRBC Abs | <=0.00 x10(3)/mcL | 0.00 | ||
| NRBC % | 0.0 – 0.0 % | 0.0 |
Basic metabolic Panel
| Component | Ref Range & Units | Results | ||
| Sodium | 136 – 145 mEq/L | 137 | ||
| Potassium | 3.5 – 5.1 mEq/L | 4.0 | ||
| Chloride | 98 – 107 mEq/L | 101 | ||
| CO2 | 22.0 – 29.0 mmol/L | 24.0 | ||
| BUN | 6.0 – 20.0 mg/dL | 13.0 | ||
| Creatinine | 0.7 – 1.2 mg/dL | 1.1 | ||
| Glucose | 74 – 109 mg/dL | 115 High | ||
| Calcium | 8.6 – 10.0 mg/dL | 9.9 | ||
| Anion Gap | 12.0 | |||
| Osmolality Calc | 275 – 295 mOsm/L | 285 |
Troponin
| Component | Ref Range & Units | Results |
| Troponin T | 0.000 – 0.010 ng/mL | <0.010 |
Magnesium
| Component Ref Range & Units Results Magnesium 1.4 – 2.6 mg/dL 1.9 |
Hepatic Function Panel
| Component | Ref Range & Units | Results | |
| Albumin | 3.5 – 5.2 mg/dL | 4.1 | |
| Total Protein | 6.6 – 8.7 g/dL | 7.1 | |
| Total Bilirubin | 0.0 – 1.2 mg/dL | 0.3 | |
| Direct Bilirubin | 0.0 – 0.3 mg/dL | <0.2 | |
| ALK PHOS | 40 – 129 U/L | 89 | |
| ALT (SGPT) | 0 – 41 U/L | 38 | |
| AST (SGOT) | 0 – 40 U/L | 27 |
Chest X-ray
CXR impression: questionable patchy/nodular opacity at the right lower lobe, partially obscured secondary to overlying material, Follow up exclude pneumonia versus neoplasia.
Impression: Cocaine intoxication with complication
Patient treated with Ativan 2mg, with relief of symptoms.
Labs and imaging reviewed with the patient.
- Labs within normal limits. EKG sinus rhythm. Troponin negative.
- CXR results revealed possible RLL pneumonia versus neoplasia, patient understands the important of follow up with primary care for further evaluation and possible referral to specialist
Vital signs are stable and the patient is clinically stable for discharge.
Patient was educated about the harms of cocaine use. Return precautions discussed in detail.
Follow Up: Patient to follow up with a primary care physician in 1 week.
Discharge – Patient is clinically stable for discharge. Verbally acknowledges and agrees with the plan, discharge instructions and follow up. All questions answered and concerns addressed.
