Chest Pain Diagnosis

A 48-year-old Caucasian male presents to your primary care office today for a refill of his medication. He takes Lisinopril and hydrochlorothiazide for his stage I hypertension. Other than hypertension, he has no other medical problems. His blood pressure today is 136/82 and he reports that he is compliant with his medications. He does not smoke, drinks alcohol occasionally, works at a sedentary job, and does not exercise. He has a BMI of 31. While doing a review of symptoms, he reports that he had to start “paying someone to cut my grass because when I cut the grass I was getting pain in my chest”. He reports that this was happening every week, only with grass cutting, and the chest pain has not occurred since he stopped cutting the grass. He reports that with grass cutting, he developed substernal chest pain that radiated to the neck, dizziness and nausea. He reports that the symptoms resolve spontaneously after stopping the activity and sitting down for 15 minutes. He presently is pain-free and has not experienced this pain in the last month.

What diagnosis can you make today? What tests should you order? What referrals should you make? What instructions should you give to the patient regarding the return of chest pain?

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