Age 58 Sex M Date
Chief complaint "Pain on my chest" on and off for the past six months.
History of present illness Mr. Solomon is a 58 year
old insurance broker who presents tonight in the office following an episode of
"chest pain" that he experienced earlier in the day during a golf game. Although
he minimizes the severity of the pain and attributes it to being "out of shape,"
his wife insisted that he see a physician because he has had similar episodes during the
past six months.
Mr. Solomon describes the pain as being more of a discomfort or
heaviness. It is localized to "my breast bone" and does not radiate. Today,
following a brief rest, the pain subsided and he returned to his golf game. Previous
episodes of the heavy feeling tended to occur following large meals and one occasion,
while dancing at a wedding. None of the episodes lasted more than "several
minutes."
Although Mr. Solomon did not experience nausea or vomiting today, he notes many episodes in the past of feeling a burning sensation in his chest. He describes the sensation as being "like acid behind my breast bone." This feeling occurs most often late at night when he lays down. Usually he has had a large meal or drank alcohol. The sensation does not radiate.
Patient's perspective: When asked about how he feels about these episodes, he admits to being concerned about his health and longevity, considering his father died at age 52 of "heart problems." He says, business is poor, my kid is always in trouble. "Who’s going to take care of things?"
Past Medical history: Not significant
Past Surgical History: None
Family History: Father died of "heart problems" at the age of 52.
Social History: Mr. Solomon smokes ½ to 1 pack of cigarettes per day. He drinks 2-3 cocktails per nights to "settle my nerves."
Medications: Vitamins
Allergies: None
Review of systems: No significant problems
Physical Examination
Mr. Solomon is a short, moderately obese man who appears somewhat anxious but is in no apparent distress. He is wearing clean casual shirt/pants. Vital sings: BP right arm 162/94; left arm 160/92. Weight 176lbs; Height 5’7". Respiratory rate is 16/minute. Temperature, 98.4º F.
Examination of cardiovascular system reveals a regular, apical heart rate of 86/minute. S1 is heard best at the apex; a loud S2 is heard best in the R2ICS and L parasternal border. A questionable S4 is heard at the apex. There are no murmurs or apical prominence. There is no peripheral edema.
Lungs are clear to percussion and auscultation. An indirect hernia is noted in the right inguinal region. The abdomen is examination is negative for abnormalities.
LABORATORY TESTS:
CBC: WBC = 5,600/mm3, hemoglobin = 15.2g/dL, hematocrit = 45%, platelet count = 320,000/mm3
Chemistries: Glucose 110mg/dL, Blood Urea Nitrogen (BUN) 11mg/dL, Creatinine 0.9mg/dL
Urinalysis: Specific gravity: 1.016; Protein, Glucose, Ketones = negative.
Chest X-ray: normal