Medical Case Study: Chest Pain

Medical Case Study Primary Patient Complaint: “Chest pain.” History of Present Illness A 28-year-old Caucasian woman who is a military spouse presents after a visit to an ED for recurrent episodes of chest pain. Approximately 1 year ago, she began waking abruptly at night feeling “like I’m going to die,” with trembling, SOB, racing pulse, and chest discomfort, lasting for 10 to 15 minutes. Her chest discomfort is described as diffuse tightness, without radiation, sweating, or nausea. Episodes were somewhat relieved by getting out of bed, walking around, and opening a window for fresh air. These episodes occurred every 3 to 4 weeks, with no known triggers; they were becoming frequent and disabling as she anticipated a recurrence. In recent months, her distress had resulted in three visits to the local ED, where she was evaluated for cardiac and pulmonary disease, ruling out AMI, angina, pulmonary embolus, and hypoglycemia (EKG, cardiac enzymes, blood work, chest X-ray were all normal). She was told “It’s in your head” and not to worry about a heart attack. The patient’s main concern was that she would keep having these frightening episodes and that medical professionals could not help. Review of Systems The patient’s ROS is positive for loneliness and anxiety that began when her husband was deployed to the Middle East. Other psychiatric symptoms are negative: depression, suicidal ideation, memory problems. Her ROS is negative for fever, night sweats, weight loss, loss of appetite, loss of energy, loss of concentration, lack or excessive sleep, loss of interest, skipped heart beats, extremity swelling, wheezing, cough, nocturia/orthopnea, and heartburn. Medical History The patient’s history is negative for major illnesses or injuries. She denies psychologic or emotional trauma. Her last routine health maintenance exam was 11 months ago for well-woman visit; results were normal. Her immunizations are up to date. She is married to an army infantry soldier who is deployed to the Middle East. They have been married 3 years and have no children. Her family lives in a different state. She denies alcohol, tobacco, or recreational drug use. She regularly walks 2 miles for exercise. Allergies No known drug allergies; no known food allergies. Medication Levonorgestrel IUD ×3 years. Physical Examination Vitals: T 37°C (98.7°F), P 80, R 14, BP 124/80 mmHg, HT 165 cm (65 in.), WT 62.5 kg (138 lbs), BMI 23, pulse ox 99%. General: Well-developed, well-nourished woman appearing stated age. Psychiatric: A&O×3, anxious appearance. Neck: No thyromegaly, nodules, bruits, or adenopathy. ENT/Mouth: Posterior pharynx unobstructed. Heart: RRR; no murmurs, gallops, rubs, clicks; PMI non-displaced. Lungs: Clear to auscultation bilaterally; no wheezes, rales, rhonchi, symmetric expansion; no chest wall tenderness. Abdomen: BS all quadrants, soft, non-tender; no hepatosplenomegaly, no masses. Extremities: Pulses 2+ and equal; no tenderness, redness, swelling, or varicosities. Based on the above information that is available to you, answer the following questions. You must explain your answers by using a scholarly resource that was published within the last 5 years. 1. 2. 3. 4. 5. 6. What are your differential diagnoses? What is the most likely Diagnosis, why? What would you like to order on patient? Labs? Imaging? Why? What are the next appropriate steps for this patient? What patient education would you recommend? Why? If not managed appropriately, what are the medical/legal concerns that may arise? Explain briefly.