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Lifestyle Issues in Cardiac Health

Patient History

The internist elicits additional history from Mr. Fowler. He has smoked one pack of cigarettes per day since age 18. He tried to stop smoking on two different occasions. Five years ago he quit for two weeks, and one year ago he quit for three weeks. During his second quit attempt, he used nicotine patches but started smoking again because of irritability and difficulty sleeping. He is aware that cigarette smoking is bad for his health and would like to stop but is pessimistic about the prospects of doing so.

His alcohol use consists of one glass of wine a day with his evening meal. He occasionally drinks one or two beers on weekends.

He does not exercise regularly. During the spring, summer and early fall, he frequently plays 9--18 holes of golf once or twice a week. While playing golf, he uses a golf cart. Previously, he played tennis once or twice a week but stopped this approximately five years ago. He eats three meals a day and snacks in the evening while watching TV. He considers his diet well-balanced; he eats meats, fruits, vegetables and bread, but acknowledges that the caloric intake is high. He uses quite a bit of salt on his food and considers his diet fairly high in fat. At various times in the past, he has consciously tried to reduce his caloric intake, but these efforts have only lasted for a week or two. He estimates that he has gained approximately 35 pounds in the last 25 years.

He always uses seat belts in a motor vehicle and does not drive after he has been drinking. On occasion, however, he does ride as a passenger with a driver who has been drinking. He works as an insurance executive and has no hobbies. In his spare time, he likes to read novels and biographies and watch TV. He is an avid sports fan and regularly attends college football and basketball games. He lives with his wife of 24 years and their 18-year-old daughter. His 22-year-old son recently graduated from college and lives approximately 500 miles away. He acknowledges that he and his wife have recently had some "problems" in their marriage. He attributes the problems to his declining libido, his wife's "change of life" and the impending "empty-nest syndrome."

1. What concerns are raised based on this history? What risk factors are evident?
2. What strategies can be used to address these concerns/risk factors?
3. What parts of the physical examination would be particularly important in this patient?