HISTORY: This is a 42-year-old male who was seen at the request family physician who presented to his office with complaint of pain in the back of the neck radiating to left arm intermittently. Also sharp sticking pain at various parts of anterior chest with occasional palpitations that have been going on for several years but today after he got the pain in the left arm, he got little panicky and thought that he was feeling a choking sensation in the throat, not getting enough air in, and symptoms of typical anxiety attack. No history of hypertension, diabetes, hyperlipidemia, or smoking. He can walk 5?10 blocks without any problem.

PHYSICAL EXAMINATION: The patient is not in any distress. Blood pressure is 120/70 mmHg. Pulse is 88 per minute and regular. Respiratory rate is 16 per minute. No conjunctival pallor. No icterus. ENT negative. No jugular venous distention. No adenopathy. Both carotids are palpable. No carotid bruit. Sinus rhythm. Grade I systolic murmur at apex. There is a questionable click heard only in sitting and upright position. Lungs are clear to auscultation and percussion. No rales or rhonchi. Abdomen is soft. No organomegaly. No pulsatile masses. No guarding or tenderness. Extremities show no edema. Pedal pulses are normal. No varicosities or leg ulcer. No evidence of clubbing or cyanosis.

EKG: EKG done while the patient was having the pain shows sinus rhythm, nonspecific T?abnormalities in precordial leads. The patient's symptoms are very atypical. His symptoms of pain in the left arm emanating from the back of the neck is musculoskeletal, most likely radiculopathy. He does have a clinical sign of mitral valve prolapse and occasional sticking pain may be related to that.

PLAN: We will take an Echo Doppler and treadmill stress test. Advised to take Toprol XL 25 mg a day and use Tylenol 10 mg q.6h. p.r.n. pain. We will reevaluate after noninvasive cardiac workup.

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