Case #2:

Mr. Caine is a 40 year old, well educated and athletic salesman who has been referred to you from the ED following presentation two weeks earlier with chest pain. He is concerned about his heart. He has had several similar episodes of chest pain in the past, usually associated with anxiety and palpitations. His last episode of chest pain was three days ago. His PMH is unremarkable. He has otherwise been in good health and has not seen a doctor since his last employment physical 5 years ago. He has a son (12) and a daughter (15) without medical problems; his father has CHF at 64 years and maybe had an MI earlier.

After your experience with Mr. User, you gently question Mr. Caine about his habits and he discloses the following additional information. He drinks 2 beers at luncheon meetings, and occasionally 2 glasses of wine with dinner. His CAGE responses are all negative for alcohol. He reluctantly admits to snorting cocaine approximately 1-2 times each week. He denies any cocaine use since his visit to the ED two weeks ago. He doesn't take prescription or OTC (over-the-counter) medications; he denies using other illicit drugs. His friends drink socially. A few close friends use cocaine. His wife, a lawyer, does not suspect his drug use. He's very good about concealing this from her. You ask the CAGE questions for cocaine use and find out that he has tried to cut down; he states he actually stopped his cocaine use since his last episode of chest pain due to his fear of a heart attack. Since he keeps his drug use a secret from all but close friends who are users, he does not get annoyed of criticism. He admits to feeling somewhat guilty over spending so much money on cocaine. He never used cocaine in the morning (eye-opener). Both of his parents drink "nearly every day" but he doesn't consider them alcoholics.

Although he was told in the ED that he didn't have a heart attack, he expresses concern about his heart and wants any and all tests or procedures done to insure that his heart is "OK"; he wants every test and offers to pay for any tests that aren't covered by his HMO.