IM/Hospitalist Consult Template

History:
- The patient presents with recurrent episodes of chest discomfort described as a sensation of tightness, primarily triggered by physical exertion such as rapid walking or climbing stairs.
- These episodes are consistently alleviated by rest.
- The symptoms have progressively worsened over the past several years.
- The patient underwent two exercise nuclear stress tests several years ago, both reported as normal.
- Daily activities are impacted due to the need to avoid exertion to prevent symptom provocation.
- The patient also reports intermittent palpitations, which are not consistently associated with the chest discomfort.

Past Medical History:
- Moderate to severe obstructive sleep apnea managed with continuous positive airway pressure therapy.
- Thyroid nodule that was biopsied and found to be benign.
- Osteoporosis.

Physical Examination:
- Blood pressure: 143/80 mmHg.
- Heart rate: 60 beats per minute.
- The patient appears well-nourished and in no acute distress.
- Heart sounds are normal without any murmurs.
- Lungs are clear to auscultation bilaterally.

Investigations:
- Two exercise nuclear stress tests several years ago, both reported as normal.

Clinical Impression:
The patient presents with progressive exertional chest tightness, which is consistently relieved by rest and has worsened over several years. Despite previously normal exercise nuclear stress tests, the clinical picture raises concern for underlying coronary artery disease. The patient also reports intermittent palpitations not always associated with chest discomfort. Physical examination is unremarkable, and vital signs are stable.

Differential Diagnosis:
Potential alternative diagnoses include coronary artery disease, microvascular angina, and non-cardiac causes such as musculoskeletal or gastrointestinal etiologies.

Assessment & Plan:
1. Other chest pain (R07.89)
- Impression, likely diagnosis: Underlying coronary artery disease
- Differential diagnosis: Microvascular angina, non-cardiac chest pain
- Investigations planned: Exercise stress test in clinic, 24-hour Holter monitor, cardiac CT angiogram, blood work to assess cardiac risk factors including cholesterol and diabetes screening
- Treatment planned: Metoprolol to be taken prior to CT angiogram to enhance image quality
- Relevant referrals: None specified

SHORT SUMMARY:
The patient is experiencing progressive exertional chest tightness relieved by rest, with a history of normal prior stress tests. Given the worsening symptoms and impact on daily activities, further evaluation is warranted. An exercise stress test, Holter monitor, cardiac CT angiogram, and blood work have been planned. The patient will follow up in 4-6 weeks to review results.