Problem Based Primary Clinic Note

Family Medicine Specialist HPI: Chest Pain Patient presents with new-onset substernal chest pain, described as a dull ache, radiating to the left arm, occurring intermittently over the past 24 hours. Worse with exertion, relieved slightly by rest. Associated with mild shortness of breath but no palpitations or dizziness. Denies fever, cough, or recent illness. Fatigue Patient reports persistent fatigue for the last two weeks, not alleviated by rest. Interfering with daily activities and concentration. Review of Systems: Cardiovascular: Positive for chest pain, shortness of breath. Negative for palpitations, orthopnoea, paroxysmal nocturnal dyspnoea, oedema. Respiratory: Negative for cough, wheeze, sputum. Gastrointestinal: Negative for nausea, vomiting, diarrhoea, constipation, abdominal pain. Musculoskeletal: Negative for joint pain, stiffness, muscle weakness. Neurological: Negative for headache, dizziness, syncope, numbness, tingling. General: Positive for fatigue. Negative for fever, chills, unintentional weight loss or gain. Physical Exam: General: Alert and oriented, appears well-nourished, slightly pale. No acute distress. Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. S1, S2 audible. Peripheral pulses 2+ and symmetrical. No peripheral oedema. Respiratory: Lungs clear to auscultation bilaterally. No wheezes, crackles, or rhonchi. Good air entry. Abdomen: Soft, non-tender, non-distended. Bowel sounds present in all four quadrants. No hepatosplenomegaly. Musculoskeletal: Full range of motion in all extremities, no tenderness to palpation. Neurological: Cranial nerves II-XII intact. Sensation intact. Motor strength 5/5 bilaterally. Assessment & Plan: Chest Pain - Diagnosis: Atypical chest pain, suspected angina pectoris - Differential Diagnosis: Gastroesophageal reflux disease, musculoskeletal pain, anxiety, pericarditis, pulmonary embolism. - Planned Investigations: Electrocardiogram (ECG) immediately, cardiac enzymes (troponin I, CK-MB), chest X-ray, complete blood count (CBC), basic metabolic panel (BMP). Exercise stress test to be considered if initial workup is negative. - Treatment Plan: Aspirin 300mg stat (if not contraindicated), sublingual glyceryl trinitrate (GTN) for pain relief, rest. Education on warning signs of myocardial infarction and when to seek urgent care. Lifestyle modifications including diet and exercise discussed. - Referrals: Cardiology referral for further evaluation. Fatigue - Diagnosis: Generalised fatigue, likely multifactorial. - Differential Diagnosis: Anaemia, hypothyroidism, sleep disorder, depression, chronic fatigue syndrome, nutritional deficiencies. - Planned Investigations: Thyroid stimulating hormone (TSH), ferritin, vitamin B12, vitamin D levels. Sleep study referral if indicated after initial blood work. - Treatment Plan: Encourage consistent sleep schedule, balanced diet, moderate exercise. Review medications for potential side effects. Follow-up in 2 weeks to review blood test results and discuss sleep hygiene. - Referrals: None at this time. Date of Note: 1 November 2024