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Consultation Details

Review, edit, and export the documentation for consultation ID: 3

Subjective:
Patient is a 45-year-old male presenting with intermittent chest pain for the last 2 weeks. Describes the pain as a pressure 'like an elephant on my chest'. Pain is located substernally, radiates to the left arm. It lasts for about 5-10 minutes and is exacerbated by exertion, like climbing stairs. Relieved by rest. He has not experienced any shortness of breath, diaphoresis, or nausea with the pain. No history of similar episodes.

Objective:
Vital Signs: BP 140/90, HR 88, RR 16, Temp 98.6°F, SpO2 99% on room air.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Distal pulses are 2+ and equal bilaterally. No peripheral edema.
Respiratory: Lungs clear to auscultation bilaterally. No wheezes or rales.
EKG: Normal sinus rhythm, no acute ST segment changes.

Assessment:
Stable angina. The symptoms are classic for cardiac chest pain. While the initial EKG is normal, the exertional nature of the pain is concerning.
Differential includes GERD, musculoskeletal pain, but cardiac etiology is highest on the list.

Plan:
1.  Schedule for a cardiac stress test within the next 48 hours to evaluate for coronary artery disease.
2.  Prescribed Nitroglycerin sublingual as needed for chest pain.
3.  Patient education on when to seek emergency care.
4.  Follow-up in 1 week to discuss stress test results.