1.

ID Info/CC
a. Angie Hart is a 62 year old Caucasian woman who presents with a chief
complaint of chest pain. Her active problems include hypertension,
borderline hyperlipidemia, and mild dyspnea on exertion.
2. HPI
a. Mrs. Hart reported a one-hour history of localized retrosternal chest
pain that began upon awakening which she described as tightness or
nagging. She said it was approximately a 5/10 in severity and that
exertion, movement, eating and palpation has not alleviated the pain.
b. This is her first occurrence of chest pain outside of mild dyspnea upon
strenuous activity such as walking up 4 flights of stairs, and she
reported no associated shortness of breath, sweating, nausea,
increased stress, cough or fever.
c. Risk factors include a 35 pack year history of tobacco use that she
successfully quit 12 years ago, a mother who died of a myocardial
infarction at 62, a father who died of emphysema at 70, as well as a 2
year history of hypertension and borderline hyperlipidemia. S
d. She is taking 40mg Lisinopril to try to control her blood pressure and is
managing her borderline hyperlipidemia by avoiding high cholesterol
foods and eating high fiber foods. Her other past medical history is
primarily unremarkable and includes gall bladder removal
approximately 36 years ago and menopause 10 years ago.
e. She exercises 2-3x a week at the gym for 30 minutes at a time and
mows the lawn weekly. In addition, she reports no alcohol or drug use.
3. PE
a. On physical examination,
i. BP: 160 / 80
ii. RR: 12
iii. HR: 80
iv. Temp: 98
v.
b. She appeared comfortable, alert and her height and weight were
measured at 56, 180lbs, giving her a BMI of 29.
c. Remarkable positive findings included
i. small yellow nodules present on both upper eyelids
ii. Arteriolar narrowing and tortuosity with scattered punctate
hemorrhages on fundis exam
iii. A left fmoral artery bruit
d. Pertinent negative findings included:
i. Lung
1. Normal chest wallwith symmetric chest expansion, normal
tactile fremitus, resonant lungs with vesicular breath
sounds
ii. CV:
1. Normal JVP height, PMI in left 5th intercostal space just
medial to midvlavicular line, Normal S1/S2, no murmurs or
rubs.
iii. Peripheral extremities:
1. Warm w/o Edema w/ strong peripheral pulses
 iv. Iv. Musculoskeletal
1. No tenderness on palpation of chest wall
4. Assesment/plan/course to date
a. The patients major presenting problem is retrosternal chest pain. The
DDX includes
i. Angina
1. +
a. Uncontrolled HTN (160/80 despite 40mg Lisinopril)
b. borderline hyperlipidemia
c. BMI = 29
d. 35 pack year tobacco history
e. Maternal MI at 62
f. Age
g. Her description of pain as tightness or nagging
h. Her left Femoral Artery Bruit
i. Previous mild dyspnea upon strenuous exercise
j. Suspected cholesterol nodules on her upper eyelids
2.
a. Pain has lasted for an hour
b. Occurring at rest for the first presentation
c. Is not worsened by exertion
d. Localized with no radiation (however angina and
acute coronary disease are more likely to present
atypically in women and her previously mentioned
dyspnea on strenuous exertion may have been
ischemic pain.
3.
ii. Gerd
1. Due to the location of the pain + overweight BMI, but is
less likely due to:
a. No association with eating
b. Abrupt onset with no progression
c. Lack of Nausea or other GI symptoms
iii. Costochondritis
1. Due to the localized nature of the pain, but is less likely
due to the lack of tenderness on palpation of the chest
wall.
b. Plan:
i. EKG to look for any ischemic cardiac signs such as:
1. ST elevations
2. Pathologic Q waves
3. Other cardiac abnormalities
ii. Aspirin for symptom and ischemic relief if etiology is chemic
iii. Advise pt to continue her low cholesterol diet and to continue
taking her 40mg Lisinopril. Once etiology of pain is determined,
consider altering htn management to control her BP to 120/80.
iv. If no etiology is found, consider test run of PPI for GERD
 v. If no etiology to support CAD/GERD found, recommend rest of
OTC analgesics for potential costochondritis to see if symptoms
improve
vi. Consider Arerial Dopper study to find etiology of the femoral
artery brui.