Case Study Week #7: iHuman 49 Years Old Patient CC: Intermittent Squeezing Chest Pain (C, Lab Reports of Personal Health

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Case Study Week #7: iHuman 49 Years Old Patient

CC: Intermittent Squeezing Chest Pain (Class 6512)

Case Study Week #7: iHuman 49 Years Old Patient CC: Intermittent Squeezing Chest Pain (Class 6512)

Case Study Week #7: iHuman 49 Years

Old Patient CC: Intermittent

Squeezing Chest Pain (Class 6512)

Reason for Encounter

A 49-year-old male presents with intermittent squeezing chest pain, which occurs during physical exertion and has been ongoing for the past 4 weeks.

Chief Complaint (CC):

"Intermittent squeezing chest pain during physical exertion."

History of Present Illness (HPI)

The patient reports experiencing intermittent episodes of chest pain over the past 4 weeks. The pain is described as squeezing or pressure-like, located centrally in the chest, and is triggered by physical exertion (e.g., walking or climbing stairs). Each episode lasts for approximately 5- minutes and is relieved by rest. The patient denies radiation of the pain to the arms, jaw, or back. He also denies associated symptoms such as nausea, vomiting, palpitations, diaphoresis, or dizziness. Mild shortness of breath accompanies the pain during exertion. The patient has a history of hypertension and hyperlipidemia, though he is currently not taking any medications for these conditions. He has a 20-year history of smoking, consuming about one pack per day, and drinks

alcohol occasionally. His family history includes his father having had a myocardial infarction at age 55. HPI Questions and Answers:

1. When did the chest pain start? ○ Four weeks ago.
2. How often does the chest pain occur? ○ Several times a week, mainly with physical activity.
3. Can you describe the pain? ○ It feels like a squeezing or pressure in the center of my chest.
4. How long does each episode of pain last? ○ About 5 to 10 minutes.
5. What triggers the pain? ○ Physical exertion, like walking or climbing stairs.
6. What relieves the pain? ○ Resting usually makes the pain go away after a few minutes.
7. Does the pain radiate anywhere? ○ No, it stays in my chest.
8. Do you experience shortness of breath during these episodes? ○ Yes, I feel short of breath when the pain occurs.
9. Do you feel lightheaded or dizzy during the pain? ○ No, I don’t feel dizzy. 10. Have you experienced nausea or vomiting? ○ No, I haven’t felt nauseous or vomited.
10. Do you notice palpitations during the episodes? ○ No, I don’t feel my heart racing.
11. Do you sweat excessively when the pain occurs? ○ No, I haven’t noticed sweating.
12. Has the pain ever occurred at rest? ○ No, it only happens when I’m active.

29. Do you have any known history of heart disease? ○ No, I haven’t been diagnosed with heart disease before.
30. Have you experienced any recent illnesses or infections? ○ No, I haven’t been sick recently.
31. Do you feel fatigued more than usual? ○ Yes, I’ve been more tired lately, especially after exertion.
32. Do you have any known lung problems? ○ No, no lung problems.
33. Do you take any medications regularly? ○ No, I don’t take any medications.
34. Have you noticed changes in your bowel or bladder habits? ○ No, everything is normal there.
35. Do you experience chest pain after meals? ○ No, it only happens when I’m active.

Past Medical History (PMH):

● Hypertension (not currently treated) ● Hyperlipidemia (not currently treated)

Family History (FH):

● Father had a myocardial infarction at age 55.

Social History (SH):

● Smokes 1 pack of cigarettes/day for the past 20 years. ● Occasional alcohol use (2-3 beers weekly). ● Denies recreational drug use.

Physical Examination (PE)

● Vital Signs: ○ Blood Pressure: 145/92 mmHg ○ Heart Rate: 82 bpm ○ Respiratory Rate: 18 breaths/min ○ Oxygen Saturation: 98% ○ Temperature: 98.6°F ● General Appearance: The patient appears well-developed, well-nourished, and in no acute distress. ● Cardiovascular: Regular rate and rhythm, no murmurs, gallops, or rubs. No jugular venous distention (JVD) or peripheral edema. ● Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or crackles. ● Gastrointestinal: Abdomen is soft, non-tender, with no masses or organomegaly. Bowel sounds are normal. ● Musculoskeletal: No chest wall tenderness. Full range of motion in all extremities. ● Neurological: Alert and oriented to person, place, and time. Cranial nerves II-XII intact.

3. Lipid Panel: ○ Total cholesterol: 240 mg/dL ○ LDL: 170 mg/dL ○ HDL: 40 mg/dL ○ Triglycerides: 180 mg/dL
4. Chest X-ray: ○ No acute findings. Normal heart size, clear lung fields.
5. Exercise Stress Test: ○ Positive for ischemia, with ECG changes suggestive of reduced blood flow to the heart during exertion.

Final Diagnosis: Stable Angina

Treatment Plan

1. Lifestyle Modifications: ● Smoking cessation: Referral to a smoking cessation program and considering nicotine replacement therapy. ● Dietary changes: Low-sodium, low-fat, and low-cholesterol diet to manage hypertension and hyperlipidemia. ● Exercise: Encourage regular moderate-intensity exercise under supervision (such as walking) to improve cardiovascular health, but advise avoiding strenuous activities until the chest pain is better managed.

2. Medications: ● Aspirin 81 mg daily: For antiplatelet therapy to prevent coronary events. ● Nitroglycerin 0.4 mg sublingual as needed for chest pain: Educate the patient on using nitroglycerin for symptomatic relief during angina episodes. ● Atorvastatin 40 mg daily: To manage hyperlipidemia. ● Metoprolol 50 mg twice daily: Beta-blocker to control heart rate and reduce oxygen demand.
3. Follow-up and Referral: ● Follow-up in 2 weeks to monitor response to treatment. ● Referral to cardiology for possible coronary angiography and further evaluation for revascularization if symptoms persist or worsen.

Summary

This case involves a 49-year-old male presenting with stable angina, characterized by exertional chest pain relieved by rest. Risk factors include a history of hypertension, hyperlipidemia, and smoking, with a significant family history of coronary artery disease. The diagnostic workup, including a positive stress test, supports the diagnosis. The treatment plan includes lifestyle modifications, medical therapy (aspirin,