Internal Medicine - New Patient

Internal Medicine - New Patient Reason for referral: Patient, Ms. Eleanor Vance, aged 62, has been referred by her family physician, Dr. Sarah Jenkins, for evaluation of recurrent dizzy spells and exertional chest pain. History of Presenting Illness Ms. Vance presents with a 6-month history of intermittent dizzy spells, occurring approximately 2-3 times per week. These episodes are often associated with standing up quickly and occasionally mild nausea but no true syncope. She also reports exertional chest pain over the past 3 months, described as a dull ache across her chest, radiating to her left arm, resolving with rest. She denies shortness of breath at rest, palpitations, or oedema. She reports no fever, chills, or weight changes. She reports some fatigue but attributes this to disrupted sleep due to anxiety about her symptoms. Ms. Vance works as a retired school teacher. She is a non-smoker. She consumes alcohol socially, approximately 2-3 units per week. Her insurance coverage is through NHS Scotland. Past Medical History Ms. Vance has a history of essential hypertension diagnosed 10 years ago, well-controlled with medication. She underwent an appendectomy in 1985. She also has osteoarthritis in her knees, managed with over-the-counter pain relievers. Medications Currently, Ms. Vance is taking Lisinopril 10mg once daily for hypertension. She also takes Ibuprofen 400mg as needed for knee pain. She denies any other regular medications, supplements, or herbal remedies. Family History Her mother had a history of coronary artery disease and type 2 diabetes. Her father passed away from a stroke at the age of 70. She has one brother who is healthy. Physical Examination Vital signs: Blood pressure 130/80 mmHg, Heart rate 72 bpm, Respiratory rate 16 bpm, Temperature 36.8°C, Oxygen saturation 98% on room air. General appearance: Well-nourished female, appearing comfortable at rest. Cardiovascular: Regular heart rhythm, no murmurs, rubs, or gallops. Normal carotid pulses, no bruits. Respiratory: Clear breath sounds bilaterally, no crackles or wheezes. Abdomen: Soft, non-tender, non-distended, no hepatosplenomegaly. Neurological: Alert and oriented, cranial nerves intact, normal motor strength and sensation bilaterally. Romberg sign negative. Investigations: Laboratory results from 25 October 2024: Hb 13.5 g/dL, WCC 7.2 x 10^9/L, Platelets 280 x 10^9/L. Electrolytes: Na 138 mmol/L, K 4.1 mmol/L, Creatinine 78 µmol/L. Glucose 5.8 mmol/L. Lipid panel: Total Cholesterol 5.2 mmol/L, LDL 3.1 mmol/L, HDL 1.4 mmol/L, Triglycerides 1.2 mmol/L. Stress test completed 30 October 2024. Resting heart rate was 68 bpm. Maximum heart rate achieved was 145 bpm. Total time on treadmill was 9 minutes. She achieved 10 METs. There were no significant ST segment changes during exercise. Resting EKG showed normal sinus rhythm with no ischaemic changes. The stress test was reported as normal. Summary Ms. Vance, a 62-year-old female, presents with recurrent dizzy spells and exertional chest pain. Her physical examination and recent stress test are largely unremarkable. The dizzy spells appear orthostatic in nature. The exertional chest pain, while concerning, has resolved with rest and the stress test was negative. Advice was given regarding hydration and slow positional changes for dizziness. Consideration was given to her family history of coronary artery disease. Plan 1. Advise Ms. Vance to increase fluid intake and change positions slowly to mitigate orthostatic symptoms. 2. Refer to cardiology for further evaluation of exertional chest pain despite normal stress test, given family history. 3. Schedule follow-up in 4 weeks to review symptoms and investigation results. Thank you very much for the kind referral. If you have any questions, don't hesitate to reach out.