Name: Brian Foster
Age: 58 years
Sex: Male
Race: Caucasian
Chief Complaint (CC): “I have been having some troubling chest pain in my chest now and then for the past month.”
History of Present Illness (HPI): Brian Foster is a 58-year-old Caucasian male presenting with troubling chest pain since the last month. The pain is situated in the middle of his chest. Currently, the pain is at zero although he rates the pain at 5/0 during the previous episodes. It is usually a tight uncomfortable feeling that is neither burning nor crushing. He had 3 episodes in the past month. The initial episode commenced with physical activity, while he was doing his yard work whilst the second episode commenced when he was taking stairs at work. The most recent episode was three days ago. These episodes lasted only for a few minutes and they all felt the same. The pain does not radiate to the neck, shoulder, back, or even to the arm and is not associated with food intake. It is aggravated by physical activity and relieved by laying down with a brief rest. Has not taken any medications for the chest pain.
Medications: Metoprolol 100 mg PO once daily, atorvastatin 20 mg PO once daily, and omega 3 fish oil 1200mg PO once daily. He occasionally takes over-the-counter medications particularly Tylenol or Motrin when having headaches. Denies aspirin use.
Allergies: codeine (nausea/vomiting). No known food allergies.
Past Medical History (PMH): He was diagnosed with Stage 2 hypertension a year ago. Also diagnosed with hyperlipidemia last year. Denies regular blood pressure monitoring, history of coronary artery disease, or previous chest pain treatments. Formerly had a heavy EKG but the last one done 3 months ago was normal. He sees his primary care provider every 6 months.
Past Surgical History (PSH): Denies any previous surgeries or blood transfusion.
Sexual/Reproductive History: Heterosexual.
Personal/Social History: Married with two children, the wife is 50 years old and well. Drinks 2 to 3 beers per week although he does not use tobacco or illicit drugs. Has not exercised regularly for 2 years. Unsure of salt intake. Diet mainly consists of granola bars, turkey subs, grilled meat, and veggies. Reports a daily water intake of 1 liter and 1 to 2 cups of coffee daily. No unusual stress was noted.
Immunization History: The last dose of TDAP was 10/2014 while his influenza vaccination is up to date.
Significant Family History: Father had hypertension, hyperlipidemia, and obesity but died at 75 years due to colon cancer. His mother is 80 years old but has type 2 diabetes and hypertension. His brother deceased at 24 years as a result of a motor vehicle accident. His sister is 52 years old and has type 2 diabetes and hypertension. Maternal grandfather experienced a heart attack at the age of 54 years while maternal grandmother died of breast cancer at the age of 65 years. Paternal grandmother succumbed from pneumonia at the age of 75 years while paternal grandfather died aged 85 years due to “old age.” He has a healthy son aged 26 years and an asthmatic daughter aged 19 years.
General: Denies fever, chills, weight loss, increased sweating, recent illness, or fatigue.
HEENT: No blurring of vision, hearing problems, runny nose, sore throat, or difficulty in swallowing.
Cardiovascular/Peripheral Vascular: Denies dizziness, palpitations, peripheral edema, history of angina, or circulation problems
Respiratory: No cough, shortness of breath, wheezing, or sputum.
Gastrointestinal: No nausea, loss of appetite, constipation, diarrhea, abdominal pain, bloating, or vomiting.
Musculoskeletal: No joint pain, swelling, stiffness
Hematological: No anemia, easy bruising, and bleeding.
Psychiatric: Denies anxiety, hallucinations, or depression.
Skin: No lesions, skin changes, or rashes.
Vital signs: blood pressure 146/88 mmHg (left arm) and 146/90 mmHg (right arm), mean arterial blood pressure- 109 mmHg. Temperature- 36.7 degrees Celsius, heart rate-104 b/min, respiratory rate-19 breaths/min, oxygen saturation- 98% on room air.
General: A middle-aged Caucasian male, appropriate for his age and well-groomed. He is alert and oriented with no acute distress. Good oral hygiene. Well hydrated and good nutrition status. No cyanosis, jaundice, pallor, lymphadenopathy, or edema.
Cardiovascular/Peripheral Vascular: Normoactive precordium on inspection. Point of maximal impulse displaced laterally. S1 and S2 heard. No murmurs or rubs. S3 heard at the mitral area. Right carotid bruit. JVP 3 cm above the sternal angle. Left carotid pulse without a thrill, 2+. Right carotid pulse with bruit and thrill, 3+. Brachial, radial, femoral pulses without a thrill, 2+. Popliteal, posterior tibial, and dorsalis pedis pulses without a thrill, 1+. Capillary refill of all the digits and toes, 2 seconds.
Respiratory: Symmetrical chest that movies with respiration with no obvious chest wall deformities. Non-tender and trachea centrally located. Resonant on percussion. Vesicular breath sounds in the upper lobes and right middle lobe. Fine crackles/rales in posterior bases of right and left lungs.
Gastrointestinal: Symmetrical, round, non-distended abdomen that moves with respiration. Umbilicus inverted with no visible scars or lesions. Soft and non-tender on both light and deep palpation, the liver span is 7 cm in the MCL and 1 cm below the right costal margin. Tympanic on percussion. The spleen and bilateral kidneys are impalpable. Normoactive bowel sounds in all the quadrants and no abdominal bruit on auscultation.
Musculoskeletal: Normal muscle bulk, power grade 5/5 across all muscle groups, normal tone, and normal reflexes. Full range of motion across all joints.
Neurological: GCS 15/15. Oriented to time, place, and person. Intact memory and speech. All cranial nerve functions are intact. Intact sensation across all dermatomes. Intact bladder and bowel function. No spinal tenderness.
Skin: dry, warm, pink, and intact. No tenting.
EKG- regular sinus rhythm, no ST changes. Fasting blood sugar and HbA1c to exclude diabetes given his significant family history of type 2 diabetes (Galicia-Garcia et al., 2020). He is on therapy for hyperlipidemia and therefore requires a lipid profile to evaluate the current level of control. Additional tests include a complete metabolic panel to isolate any underlying electrolyte abnormalities, liver function tests to check liver function, and a complete blood count as a baseline for treatment. Similarly, cardiac enzymes and brain natriuretic peptide are required to exclude myocardial infarction since chest pain can be caused by myocardial infarction. Imaging studies include Doppler ultrasound to assess peripheral pulses, chest x-ray to check for any abnormal opacifications, and echocardiography to determine the ejection fraction or any structural lesions of the heart. Finally, CT angiography to detect any carotid diseases since the right carotid had a bruit.
Brian Foster presents with retrosternal chest pain that worsens with exertion but is relieved by rest. This is typical of angina pectoris. For an unknown reason, his chest pain does not radiate to the neck, jaw, left arm, or shoulder. According to Ferrari et al. (2019), angina pectoris is usually an indication of coronary artery disease. Coronary artery disease refers to an ischemic heart disease resulting from the narrowing of coronary vessels resulting in diminished blood flow to the myocardium. His angina is stable since it follows exertion and is relieved by rest (Ferrari et al., 2019). According to Krittanawong et al. (2020), an estimated 90% of coronary artery disease stems from atherosclerosis. Brian Foster has risk factors for atherosclerosis including hypertension, alcohol intake, male sex, hyperlipidemia, and an inactive lifestyle (Krittanawong et al., 2020).
Brian Foster also has uncontrolled hypertension evidenced by persistently elevated blood pressure despite being on antihypertensives (Oparil et al., 2018). He also experiences occasional headaches which might be a result of elevated blood pressure. He was also diagnosed with hyperlipidemia a year ago. Hyperlipidemia refers to elevated lipid levels in the body. According to Su et al. (2021), hyperlipidemia is a risk factor for several cardiovascular disorders and therefore must be controlled. He is currently on atorvastatin and it is elemental to determine the level of control through a lipid profile. Additionally, Brian Foster has an inactive lifestyle evidenced by a lack of regular physical activity.
Brian Foster could also be having a silent myocardial infarction. Myocardial infarction is a consequence of an imbalance between myocardial oxygen demand and supply (Saleh & Ambrose, 2018). It is a common cause of retrosternal chest pain. However, the lack of ST changes on EKG points towards non-ST elevated myocardial infarction (Saleh & Ambrose, 2018). Similarly, Brian Foster has clinical manifestations of heart failure including an S3, displaced apex beat, and bilateral crackles/rales (Schwinger, 2021). He also has hypertension and dyslipidemia which are important risk factors for heart failure. Consequently, further assessment is required to exclude this condition. Finally, he could be having a peripheral vascular disease (asymptomatic) due to diminished peripheral pulses.
Ferrari, R., Censi, S., & Squeri, A. (2019). Treating angina. European Heart Journal Supplements: Journal of the European Society of Cardiology, 21(Suppl G), G1–G3. https://doi.org/10.1093/eurheartj/suz190
Galicia-Garcia, U., Benito-Vicente, A., Jebari, S., Larrea-Sebal, A., Siddiqi, H., Uribe, K. B., Ostolaza, H., & Martín, C. (2020). Pathophysiology of type 2 Diabetes Mellitus. International Journal of Molecular Sciences, 21(17), 6275. https://doi.org/10.3390/ijms21176275
Krittanawong, C., Kumar, A., Wang, Z., Narasimhan, B., Mahtta, D., Jneid, H., Baber, U., Mehran, R., Tang, W., Ballantyne, C. M., & Virani, S. S. (2020). Coronary artery disease in the young in the US population-based cohort. American Journal of Cardiovascular Disease, 10(3), 189–194. https://www.ncbi.nlm.nih.gov/pubmed/32923100
Oparil, S., Acelajado, M. C., Bakris, G. L., Berlowitz, D. R., Cífková, R., Dominiczak, A. F., Grassi, G., Jordan, J., Poulter, N. R., Rodgers, A., & Whelton, P. K. (2018). Hypertension. Nature Reviews. Disease Primers, 4(1), 18014. https://doi.org/10.1038/nrdp.2018.14
Saleh, M., & Ambrose, J. A. (2018). Understanding myocardial infarction. F1000Research, 7, 1378. https://doi.org/10.12688/f1000research.15096.1
Schwinger, R. H. G. (2021). Pathophysiology of heart failure. Cardiovascular Diagnosis and Therapy, 11(1), 263–276. https://doi.org/10.21037/cdt-20-302
Su, L., Mittal, R., Ramgobin, D., Jain, R., & Jain, R. (2021). Current management guidelines on hyperlipidemia: The silent killer. Journal of Lipids, 2021, 9883352. https://doi.org/10.1155/2021/9883352