Cardiology - Report 4

Cardiology

TAPE 8A, Report 4

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT

Pain in the chest.

HISTORY OF PRESENT ILLNESS

This is a 40-year-old gentleman referred to this office because of pain in the chest.  He states that this pain has been present in the area for some time.  The pain is radiating in nature, and the patient is worried about it.

PAST MEDICAL HISTORY

There is no diabetes or history of rheumatic fever in the past.  The patient says, “I’m really pretty healthy.”

SOCIAL HISTORY

He is a 1-pack-a-day cigarette smoker.  EtOH intake is negative.

FAMILY HISTORY

His parents both died as a result of strokes.  There is no known family history of heart disease.

PHYSICAL EXAMINATION

NECK:  The neck is supple.  There are no carotid bruits.

CHEST:  Lungs are clear to percussion and auscultation.

HEART:  PMI is not displaced.  PMI is in the fifth intercostal space.  There is no thrill, heave, gallop, rub, or murmur.

LABORATORY DATA

The electrocardiogram is within normal limits.

The patient was subjected to a treadmill stress test.  Using the protocol of Ellestad, he reached a maximum pulse rate of 150, which was 93% of his maximum predicted heart rate.  There were no abnormalities noted before the exam, there were no abnormalities noted during the exam, nor after the exam.  He had a good response to all phases of this testing.

DIAGNOSES

1. Chest pains, not on a cardiac basis.

2. Possible musculoligamentous sprain in the costal area.

3. Some risk factors for cardiovascular disease, including heavy cigarette smoking.

DISCUSSION

I find no frank evidence of cardiac problems in this gentleman.  However, I believe with some modification of his lifestyle, including the discontinuation from smoking and losing several pounds of weight, he can enjoy good health for many years.  As noted above, his treadmill stress test was interpreted as being completely normal.  The patient’s present episodes of chest pain are probably only on a musculoskeletal basis and are to be treated with oral analgesics such as aspirin or perhaps Parafon Forte.

FOOTNOTE

Line 16 (Page 1).  The heading Past Medical History was added.

Line 21 (Page 1).  Alternative:  ETOH.