Patient comes in to the ER with a chief complaint of chest pain. This patient is well known to me due to his
multiple visits regarding hypertensive episodes. The chest pain started last night after playing football. The patient rated the severity of the pain as 8 out of 10. Pain is worse when sitting up. Patient describes the pain as sharp. He hasn't done any heavy lifting. He has no allergies to medications. The patient doesn't smoke and is married The patient has had no vomiting, fevers/chills, dizziness, sore throat, other muscle pain, blurred vision, urinary frequency, rashes, shortness of breath, besides chest pain no other cardiovascular symptoms, no numbness, or symptoms of depression.
Temp: 98.4, Pulse: 60, BP: 140/110. Heart: RRR, no murmurs, carotid pulse strong, no edema in extremities. Lungs Clear to auscultation. Musc: No pain to palpation in upper arms. Abd: not tender, no masses, ENT: throat normal, Eyes: pupils equal and reactive. Neck lymph nodes: no enlargement. Patient is oriented to time, place and person. Performed and personally reviewed EKG which was normal. Cardiac Enzymes came back normal. Chest X-rays: report said normal, and after reviewing films agree that they are negative.
1. Chest pain most likely non-cardiac in nature. Pain resolved with pain medication.
Since blood pressure was high here in the ER, recommending that patient follow up with his regular physician to have his HTN assessed. Patient is to return to the ER if chest returns.
Assign the appropriate E&M (using 1995 E&M guidelines) and diagnosis codes.
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