“chest pain and almost choking”

Patient is a 89 year old white male who was in his usual state of health until the morning of admission when he presented to the emergency department complaining of  3 distinct, sudden episodes of chest pain, back pain, abdominal bloating, and facial flushing.  Each episode lasted approximately 1 to 2 minutes and rapidly resolved.  He also described a choking sensation during the episodes in which it was difficult to “catch his breath and speak”.  Associated symptoms that were present of day of admission were mild weakness and nonproductive cough.  He had no further complaints.

1. Myasthenia Gravis since 2002 during which time he had suffered from respiratory failure secondary to aspiration
2. Congestive Heart Failure – questionable diagnosis with last TTE on April 01 that was normal (normal LV/RV size, EF 45-49%)
3. Hypothyroidism
4. Arrythmia – questionable atrial flutter
5. Chronic iron deficiency anemia secondary to multiple gastric and colonic polyps – recent colonoscopies done 2 weeks PTA, 4/03, 11/02, and 8/02
6. Questionable history of coronary artery disease – no history of catheterization
7. Benign prostatic hypertrophy
8. Chronic left foot drop
9. Chronic renal insuffiency
10. Chronic low back pain with history of lumbar spinal surgery in the remote past

1. Prednisone 15 mg PO qD
2. Pyridostigmine 60 mg PO QI
3. Glycopyrrolate 1 mg PO TID
4. Amiodarone 200 mg PO qD
5. Omeprazole 20 mg PO qD
6. Levothryoxine 88 mcg PO qD
7. KCl 10 meq PO BID
8. Furosemide 80 mg PO qD
9. Sertraline 50 mg PO qD
10. Finasteride 5 mg PO QHS
11. Aspirin 81 mg PO qD
12. Calcium + D 1200 mg PO qD
13. Multivitamin

He denied any fever, chills, headache, nausea, vomiting, leg swelling, diplopia, dysphagia, or slurred speech. 

Vital signs in the ED: Afebrile, BP 71/44, Pulse 77, Resp 20

General: Alert and oriented in no acute distress

HEENT: within normal limits

Neck: no bruits heard, no JVD

Chest: clear to auscultation bilaterally, normal fremitus, no wheezes

CV: Regular, I-II/VI SEM, no S3 or S4 heard

Abd: soft, slightly distended, normoactive bowel sounds, no organomegaly

EXT: no c/c/e.  Pulses equal in all four extremities

Neuro: CN II-XII are intact. Speech normal

Motor exam normal.  Left foot dorsiflexion is weak (chronic).  No other abnormalities.