Clinical vignettes are used to give a graphic picture of a clinical situation. Details regarding the patient's case are presented in an objective manner. A discussion of rationale for care may be included. The American College of Physicians describes these case reports as the oldest form of medical communication. The U.S. Centers for Disease Control and Prevention estimates that more than 26 million Americans have heart disease. These three vignettes highlight typical heart disease scenarios as seen in the office of a cardiologist.
Coronary Artery Disease
A 72-year-old black male presents with coronary artery disease. He has smoked a pipe since the age of 20. He denies alcohol use and illicit drug use. He has been married for 46 years; his wife remains healthy. He eats a fair diet but states that he hates fruit and milk. He consumes red meat five times a week. On this visit, he complains of intermittent fatigue and an inability to manage his garden this year due to quick tiring. Examination reveals regular heart sounds, clear lungs and a mild tremor of the left hand. His weight is 160 pounds and his height is 5-foot, 10-inches. His temperature on examination is 98.0. His heart rate is 82. His sitting blood pressure is 100/70 and his standing pressure is 100/68. His respiratory rate is 24. EKG reveals normal sinus rhythm. Lab work is normal except for an elevated blood cholesterol of 240. He has been taking valsartan/hydrochlorothiazide 160 mg/12.5 twice a day for the past two years. He takes a baby aspirin at bedtime. Discussion: Fatigue may be age-related or due to attempting to over-work. Instructed patient and his wife on a low-fat, low-cholesterol diet. Will recheck cholesterol in 2 months and prescribe a statin if cholesterol level remains elevated. Will reduce valsartan dose to 80 mg twice a day while maintaining same dose of hydrochorothiazide. Plan to continue aspirin. Once again recommended that he quit smoking.
Chest Pain
A 50-year-old widowed caucasian female presents with complaints of chest pain several times a month. She reports the pain lasts for 5 to 10 minutes and presents as a dull ache in the middle of her chest. She reports anxiety and sweating with each episode. One episode made her nauseated for 30 minutes. The chest pain occurs after physical activity. She has no prior history of heart disease or other chronic conditions. She claims to eat a healthy diet but too many snacks at night. She denies tobacco, alcohol or illicit drug use. Her weight is 225 pounds and she is 5-foot, 4-inches tall. She takes no medications. Her blood pressure is 160/96, heart rate 102, respirations 20 and temperature 99.0. EKG reveals sinus tachycardia. Examination is negative for significant findings. Discussion: Will order echocardiogram. Will prescribe reserpine 0.1 mg and clopamid 5 mg each day for hypertension and have her return in one week for followup blood pressure measurement. Will order a CBC and chemistry workup today. Have instructed her on a healthy weight loss regimen, including a 1,500 calorie diet. Will instruct her on exercise after results of echocardiogram and possible stress test.
Alcohol- and Smoking-related Condition
A 60-year-old twice-divorced Caucasian male presents with a long history of alcoholism. He consumes six beers each day and smokes two packs of cigarettes. He had a heart attack 10 years ago and refuses to take any medication. Both of his parents died of a heart attack in their 50s. States his diet is "lousy." Blood pressure 156/100, heart rate 90, respirations 24, temperature refused. EKG and blood work refused. Denies chest pain. He is here only on insistence of his new girlfriend. Examination reveals jaundice, diminished lung sounds and enlarged liver. Discussion: Will explain importance of blood pressure control and healthy eating habits. Will also discuss importance of quitting or cutting back on cigarettes and excessive alcohol consumption. Will refer to an internal medicine specialist to follow-up on liver enlargement.
