Patient
42-year-old male, new patient
Chief Complaint
Chest pressure, left-sided, 3 weeks duration.
History of Present Illness
Patient reports dull, substernal chest pressure radiating to the left arm, onset approximately 3 weeks ago. Pressure is intermittent, worse with exertion, lasts 5-10 minutes, relieved by rest. Denies shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, palpitations, or syncope. No recent illness or fever.
Past Medical History
Hypertension, diagnosed 8 years ago. Hyperlipidemia. No prior cardiac workup.
Medications
Lisinopril 10 mg daily (reports inconsistent adherence). Atorvastatin 20 mg at bedtime (recently started).
Allergies
NKDA
Social History
Occasional ethanol use (2-3 drinks/week). Never smoker. Works as software engineer, sedentary occupation. Lives with spouse and two children.
Family History
Father: MI at age 58. Mother: HTN, T2DM. Brother: hyperlipidemia.
Review of Systems
Constitutional: denies fever, chills, weight change. Cardiovascular: chest pressure as above, no edema, no claudication. Respiratory: negative. GI: negative. GU: negative. Neuro: negative. Endocrine: denies polyuria, polydipsia.
Physical Examination
General: well-developed, NAD, no acute distress. Vitals: BP 148/92, HR 78, RR 16, Temp 98.6 F, SpO2 98% RA. CV: RRR, no murmurs, gallops, or rubs. JVP not elevated. No peripheral edema. Lungs: CTAB bilaterally. Abdomen: soft, NT/ND, no HSM.
Assessment & Plan
1. Chest pain, likely atypical vs. early CAD given risk factors.
- ECG today: normal sinus rhythm, no ischemic changes
- Labs: BMP, lipid panel, HbA1c
- Stress test referral (exercise treadmill)
- Return in 1 week for results; counsel on medication adherence
- Low-sodium DASH diet, aerobic exercise 150 min/week