South University A 60 Year-Old Woman with Chest Pain Case Discussion

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Description

This week, complete the Aquifer case titled “Internal Medicine 02: 60-year-old woman with chest pain

Apply information from the Aquifer Case Study to answer the following discussion questions:

  • Discuss the history of present illness that you would take on this patient in preparation for the clinic visit. Include questions regarding Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity (OLDCARTS).
  • Describe the physical exam and diagnostic tools to be used for Ms. Johnston. Are there any additional you would have liked to be included that were not?
  • What plan of care will Ms. Johnston be given at this visit; what is the patient education and follow-up?

You are working with Dr. Lorenzen, who asks you to start interviewing Susan Johnston, a patient she knows well who is here to discuss recent symptoms of chest pain.

You proceed to the patient’s room and review the chart before going into the room.

You learn that Susan Johnston is a 60 year-old female with a history of hypertension and dyslipidemia. On today’s chart the medical assistant has indicated that Ms. Johnson is having episodes of chest discomfort, and has recorded the vitals:

Vital signs:

  • Temperature:6 Fahrenheit
  • Heart rate: 82 beats/minute
  • Respiratory rate: 14 breaths/minute
  • Oxygen saturation: 94% on room air
  • Blood pressure: 138/78 mmHg
  • Weight: 220 pounds
  • Height: 5’ 6”
  • I’ve reviewed your chart, Susan, but I’d like to hear you describe why you wanted to be seen by the doctor today?”
  • “I have been having a strange sensation in my chest for the past 3 months and I decided it was time I should have the doctor look into it.”
  • “Can you describe this discomfort you’ve experienced?”
  • “Yes. It is right in the middle of my chest and it feels like burning at times and sometimes a tingling sensation. It always goes away, but it is starting to concern me.”
  • “When do you get these pains?”
  • “Sometimes the pain occurs when I am active, like climbing stairs, but other times it can occur when I am just sitting watching TV.”
  • “Have you passed out or felt dizzy?”
  • She denies any episodes of feeling dizzy or passing out. “No, none of that.

 

With further questioning you discover that at its worst it was a 6 out of 10 in severity. She feels short of breath when the sensation occurs but does not have diaphoresis, nausea, vomiting, dyspepsia or belching, or palpitations. There is no change in the pain with changes in body positioning. The discomfort does not radiate to her neck, jaw or arm. She has never been awakened from sleep with the sensation. The discomfort is not occurring more frequently and is not changing in its severity.

Medications and history

HISTORY

Susan tells you she has never had any kind of heart problem, and has never been told she has a heart murmur. She has a history of high blood pressure, and Dr. Lorenzen had also recommended she take a medication for elevated cholesterol but she has not started the cholesterol medication. When you ask why, she states, “I don’t like taking pills.”

Medications:

  • Lisinopril 20 mg daily
  • Hydrochlorothiazide 25 mg daily
  • She occasionally takes an aspirin but not every day, as it gives her dyspepsia.

Review of Systems: Unremarkable except she has slowly gained weight over the last 15 years.

Social History: Susan has never smoked. She drinks alcohol rarely, does not use recreational drugs and is monogamous in a married relationship for many years. She has two grown children and works as a secretary. She does not exercise on a regular basis. Dietary history was not detailed but she did admit to eating “quite a bit of fast food.”

Family History: Her father died of a heart attack at age 57. Mother is alive and in relatively good health. One sister has “adult-type diabetes.”

You present the information you have obtained so far to Dr. Lorenzen, then she suggests you both return to the room for Susan’s physical examination.

The findings from the physical examination are:

Vital signs:

  • Temperature:6 Fahrenheit
  • Heart rate: 82 beats/minute
  • Respiratory rate: 14 breaths/minute
  • Body Mass Index:5 kg/m2
  • Blood pressure: 136/82 mmHg
  • Weight: 220 lbs
  • Height: 5’ 6”

Head, eyes, ears, nose and throat (HEENT): No abnormalities.

Neck: No thyromegaly, jugular venous distension or carotid bruits.

Heart: The cardiac point of maximal impulse (PMI) is not palpable. There is no tenderness to palpation of the chest wall. Auscultation reveals a normal S1 and S2 with no murmurs, rubs or gallops.

Lungs: Normal lung excursion with normal lung sounds.

Abdomen: Obese, soft and nontender. There is no hepatomegaly or splenomegaly.

Extremities: No edema.

Vascular: Pulses in radial, carotid, and dorsalis pedis arteries are brisk, symmetric and 2+ bilaterally.

Susan Johnston is a 60-year-old female with a past history of obesity, hypertension and dyslipidemia and a family history of cardiac disease who presents with a three month history of intermittent burning anterior chest pain associated with SOB, that seems to occur with exertion and improve with rest. Other than hypertension and her elevated BMI, her physical exam is within normal limits.

The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

  1. Epidemiology and risk factors: 60-year-old female with history of obesity, hypertension and dyslipidemia and family history of cardiac disease.
  2. Key clinical findings about the present illness using qualifying adjectives and transformative language:

Question

Which of the following are the top two diagnoses on your differential at this point?

The best options are indicated below. Your selections are indicated by the shaded boxes.

  • Aortic dissection (AD)
  • B. Angina
  • Pulmonary embolus (PE)
  • D. Gastroesophageal reflux disease (GERD)
  • Myocardial infarction (MI)
  • Musculoskeletal pain
  • Pleurisy
  • Pneumothorax
  • Lorenzen asks for your assessment of Susan’s chest pain. You tell her that at this point you feel angina is a possible diagnosis. From your reading on angina, you know that you should try to characterize the patient’s symptoms as typical angina vs. atypical angina.
  • Susan has a burning sensation in her chest associated with dyspnea which occurs with exertion and usually resolves with rest. While the reliable onset with exertion and usual improvement with rest are consistent with typical angina, the burning and tingling quality of her chest pain and lack of radiation are not typical features of angina. You think her symptoms would be considered atypical angina. Dr. Lorenzen agrees with you.
  • Because Susan’s discomfort has been present for three months, seems to follow a relatively predictable pattern, and has not worsened in severity, frequency, or occurred at rest, her chest pain, if angina, would be characterized as stable angina.

 

What is your interpretation of Susan’s ECG?

This electrocardiogram reveals sinus rhythm with a normal axis of electrical activity and has normal PR and QRS intervals. There are flat T waves in lead III and inverted T’s in V1. These are nonspecific changes and may be normal for the patient. It would be helpful to have a previous ECG to compare.

 

 

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