Name: Mr. Tan Wei Ming
Age: 52 years old
Background: Mr. Tan Wei Ming is a 52-year-old Chinese Singaporean who works as a secondary school teacher. He is married to Mrs. Tan, who is 50 years old. They have two children, a son named Jun Wei, who is 25 years old, and a daughter, Li Ying, who is 22 years old. His last clinic visit was 6 months ago for an annual health checkup.
Opening Statement: Mr. Tan presents to the clinic complaining of intermittent chest pain he's been experiencing for the past two weeks.
History of presenting complaint: Mr. Tan describes the pain as a dull, heavy sensation in the center of his chest. The pain typically lasts for 10-15 minutes, usually occurring during physical exertion, such as climbing stairs or walking quickly, and subsides with rest. He denies any associated shortness of breath, dizziness, or sweating.
Past medical and surgical history: Mr. Tan has a history of hypertension and hyperlipidemia, for which he is on medication. No history of surgeries.
Current medications: Amlodipine 5mg once daily, Atorvastatin 20mg once daily.
Family history: Father had a myocardial infarction at the age of 60. Mother has type 2 diabetes.
Social history: Non-smoker. Drinks alcohol socially, about twice a month.
Lifestyle: Sedentary lifestyle, mainly due to his job. Consumes a diet high in sodium and saturated fats.
Ideas, concerns, expectations:
- "Could this pain be something serious, like heart disease?"
- "Should I stop exercising when I feel the pain?"
- "Will I need surgery?"
Behaviour: Mr. Tan appears anxious and concerned about his symptoms. He is cooperative and provides clear information about his symptoms and history.
Notes: Consider psychosocial aspects as chest pain could be due to anxiety or panic disorder.
Physical examination: On examination, his vital signs are stable. Cardiovascular examination reveals normal heart sounds, no murmurs, rubs or gallops. No clinical signs of heart failure.
Investigations: An ECG shows ST-segment depression during an episode of chest pain, which resolves after the pain subsides.
Diagnosis and Differential diagnosis: The diagnosis for this case is Stable Angina. The differential diagnoses include Unstable Angina, Myocardial Infarction, Gastroesophageal Reflux Disease (GERD), and Costochondritis.
Management Plan: The management would include lifestyle modifications, such as dietary changes and increased physical activity, continuation and potential adjustment of current medications, and introduction of anti-anginal medication such as nitroglycerin for symptom relief. A referral to cardiology for further evaluation and management may be needed.
Safety Netting: Mr. Tan should be advised to seek immediate medical attention if his chest pain becomes more frequent, lasts longer, occurs at rest, or is associated with other symptoms such as shortness of breath, dizziness, or fainting. He should also be advised to follow up regularly with his primary care provider to monitor his condition and adjust his treatment plan as necessary.