C.D, a 55-year-old African American male, presents to his primary care provider with symptoms of a headache and chest pressure that have been present for the past two days. To fully understand C.D’s medical history, family history, lifestyle factors, and current symptoms, it is necessary to perform a detailed assessment.
In terms of medical history, C.D reports being diagnosed with allergic rhinitis, depression, and hypothyroidism. It is also important to note that C.D’s father died from an acute myocardial infarction (AMI) at the age of 49 and had hypertension. C.D’s mother has both diabetes mellitus (DM) and hypertension, and his brother passed away at the age of 20 due to complications of cystic fibrosis. Additionally, C.D has two younger sisters who are alive and well. These familial medical conditions may provide important clues for assessing C.D’s risk factors and potential underlying conditions.
C.D’s social history reveals that he has been married for 25 years and lives with his wife and two children. He works as an air traffic controller at the local airport. C.D engages in unhealthy lifestyle behaviors, such as smoking a pack of cigarettes per day for the past 15 years and consuming several beers every evening to relax. He also admits to not paying attention to the sodium, fat, or carbohydrate content of the foods he eats. C.D frequently salts his food, sometimes even before tasting it. Additionally, he denies ever dieting or exercising, indicating a lack of focus on maintaining a healthy lifestyle.
C.D reports that his overall health has been fair to good in the past year. However, he notes a significant weight gain of approximately 30 pounds within the last 12 months. He also mentions experiencing occasional chest pressure and headaches over the past two days. Other symptoms that C.D reports include shortness of breath at rest, headaches, nocturia, nosebleeds, and hemoptysis. He further states that shortness of breath increases with activity, particularly when climbing stairs, and that his breathing difficulties are worsening. C.D denies any nausea, vomiting, diarrhea, or blood in his stool. He does self-treat occasional right knee pain with over-the-counter ibuprofen but denies any genitourinary symptoms.
Upon physical examination, C.D’s blood pressure (B/P) is found to be 190/120 mmHg, heart rate (HR) is 73 beats per minute, respiratory rate (RR) is 18 breaths per minute, temperature (T) is 98.8°F, height (Ht) is 6’1″, and weight (Wt) is 240 lbs. Examination of his tympanic membranes (TMs) reveals them to be intact and clear throughout. There is no evidence of nasal drainage or exudates in the oropharynx. Pupils are equal, round, and reactive to light and accommodation (PERRLA). Funduscopy reveals mild arteriolar narrowing without signs of nicking, hemorrhages, exudates, or papilledema. C.D’s neck is supple without masses or bruits, and his thyroid is found to be normal. No cervical lymphadenopathy is detected. Bilaterally, there are mild basilar crackles upon auscultation, but no wheezes are heard. On cardiac examination, C.D’s heart sounds are regular (RRR) and there are no murmurs or rubs. The abdomen is soft and non-distended, with no masses, bruits, or organomegaly noted. Bowel sounds are normal. Movement of all extremities is intact, and no sensory or motor abnormalities are observed. Cranial nerves (CNs) II-XII are intact, and deep tendon reflexes (DTRs) are 2+. Muscle tone is assessed as 5/5 throughout.
Based on this comprehensive assessment, C.D presents with a combination of symptoms that warrant further investigation and consideration of potential underlying conditions. The elevated blood pressure, headaches, chest pressure, shortness of breath, and recent weight gain are particularly concerning. Given C.D’s significant risk factors, such as his smoking history, family history of hypertension and cardiovascular disease, and unhealthy lifestyle behaviors, it is crucial to evaluate him for possible cardiovascular issues. Additional investigations, such as further cardiac and pulmonary assessments, as well as laboratory tests, may be necessary to identify the underlying cause of C.D’s symptoms and develop an appropriate management plan.