Case Analysis Discussion Paper

Chief Complaint (CC): 50 year-old patient J.S. came in complaining of chest discomfort which he described as a burning sensation under the breastbone. Case Analysis Discussion Paper

History of Presenting Illness (HPI): Patient J.S. is a 50 year-old Native American male who admits to having a previous history of this kind of chest pain but which he ignored because it was not very severe. The current symptom started three days ago after he went walking (isotonic aerobic exercise) as he had been advised to do because of his obesity (high body mass index or BMI). The location of the pain is directly below the sternum or breastbone where the pain originates and is more intense in severity. The burning chest pain under the sternum is intermittent in duration and has typically been lasting for about five minutes before stopping and coming back again. The characteristic of the pain is that it is sharp, burning, and constricting in nature. He admits noting that the pain is aggravated by physical exertion as was the case at the beginning when he went out for a walk. He also admits that the pain is relieved by rest or cessation of physical exertion. The timing of the pain is any time as long as he tries to engage in a physical activity. On a pain scale of 1-10, patient J.S. rates his chest pain at 6/10.

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Current Medications: He denies being on any medications at the moment, including home remedies or over the counter medications.

Allergies: He also denies any history of allergies; be it to any drug components, food, or environmental agents such as dust and pollen. He denies having ver had any reaction such as angioedema or anaphylaxis. Case Analysis Discussion Paper

Past Medical History (PMHx): He admits to having had all immunizations as a child. As an adult, he also admits to having received flu vaccination. His last tetanus injection was a booster dose that he received at age 35 years when he had an accidental cut on his finger while cutting a tree using a power saw. He admits to a history of obesity and several comorbidities. These are hypothyroidism, hypertension, hyperlipidemia, and type II diabetes mellitus. He has been on treatment for all these comorbidities but admits to non-adherence to medications as required. As a matter of fact, he is currently supposed to be on medications for his comorbidities but has not been able to go for a refill of the same. He claims to have been tied up by his logging business. Due to this non compliance to medication schedules, he admits that he has suffered several complications arising from his chronic conditions. One of these that he was told by his primary physician is the diabetic sore on his right foot that is currently infected and draining pus. His last clinic appearance was one year ago.

Past Surgical History (PSHx): He admits that the only surgical history that he has is the outpatient suturing of his left index finger after he accidentally almost severed it by a power saw in the line of hi work.

Social History: He reports that he is in the logging business in the countryside and has been doing so since his youth. His major hobbies are hunting and picnicking in the woods. He is a divorced father of two grown adult male children who live in other states. He currently lives alone and does not really have a social support system or anyone to remind him to take his medications. He has been a smoker of a pack of cigarettes a day for the last twenty five years and still smokes despite being advised by his primary physician to stop. He occasionally drinks etoh, especially over the weekends when he sometimes engages in binge drinking with his friends. He states that he currently does not own a car but always wears a seatbelt when he is in one. He lives in the countryside where homesteads are scattered without much environmental pollution.

Family History: He admits that his father suffered from diabetes, hypertension, and obesity and died of a heart attack (myocardial infarction or MI). His mother was also hypertensive and overweight and died of a massive stroke. His first born son is diabetic and his second born is hypertensive. He has three siblings one of whom is deceased (died of insulin overdose). His two remaining siblings are both hypertensive but only one is diabetic with hypercholesterolemia. He has five grandchildren none of whom has been diagnosed with any chronic illness so far. Case Analysis Discussion Paper

Review of Systems (ROS)

General: He reports frequent fatigue, weakness, fever, and weight gain.

HEENT: He denies double vision, blurred vision, or short-sightedness. Also denies any hearing loss, pain, otorrhea, or tinnitus. He denies rhinorrhea or sneezing and also does not have a sore throat.

Integumentary: He denies any sort of skin rashes, eczema, or abnormal itching. However, he reports having brittle nails and hair as well as skin that is dry.

Gastrointestinal: He reports bowel movements that are sometimes not regular. For instance, the last time he reports having a bowel movement was two days earlier. He denies having diarrhea, vomiting, or nausea.

Cardiovascular: He reports chest pain that is sharp and burning in nature but denies having palpitations or fainting. He also denies ever having pale extremities

Respiratory: He denies having shortness of breath or any difficulty in breathing.

Genitourinary: He reports having lost sexual drive and having a low libido. He also accepts having some problems with dribbling but denies frequency of micturition. He also denies passing cloudy urine or having pain/ burning sensation when passing urine.

Neurological: He reports paraesthesia or a tingling sensation in the upper extremities (hands and fingers) as well as numbness in the same places. He however denies ever fainting or feeling dizzy.

Musculoskeletal and Extremities: He reports frequent muscle aches and cramps. He also reports weakness of the limbs and slow movements at some times of the day. He also admits having some joint stiffness. He admits a purulent discharge from an infected sore in his right leg which has not been treated.

Endocrinologic: He denies passing excessive volumes of urine or but admits to drinking a lot of water due to excessive thirst most of the day. He denies being heat intolerant or sweating excessively.

Lymphatics: He denies having swollen lymph nodes or ever having a splenectomy surgical operation. Case Analysis Discussion Paper

Hematologic: He denies any sort of unwarranted bleeding, ease of bruising, or dizziness.

Psychiatric: He accepts experiencing periods of anxiety and depression and having a feeling of guilt and self-blame.

Allergic/ Immunologic: He denies having any allergies; be they related to medications, the environment, or foods. Also denies ver suffering from asthma, eczema, allergic dermatitis, rhinitis, or hives.

Objective

General: Patient J.S. is overtly obese and displays a labored gait. He is appropriately dressed for the time of the day and the weather and is alert and oriented in place, person, space, and time. His speech is coherent, his mood and affect congruent, and his insight is intact. He is showing moderate distress and his mucous membranes are moist. His skin turgor is fair although the skin appears dry. His vital signs are T: 38.2°C (100.76°F); BP: 150/95 mmHg; RR: 18/ min; P: 96 b/m. BMI: 31.4 kg/m2.

Head: Patient J.S.’s head is normocephalic and is evidently atraumatic.

EENT: His pupils are both equal, round, and reactive to both light and accommodation (PERRLA). The extraocular muscles are also intact. On otoscopy there is no otorrhea bilaterally or erythema. Both tympanic membranes are intact. He does not have rhinorrhea or nasal polyps. His tongue can protrude straight and the throat shows no signs of an exudate or erythema. Nuchal rigidity is absent and the neck has a full range of motion with no overt lymphadenopathy.

Respiratory: There is no dullness to percussion, no tactile fremitus, no increase in breath sounds, and no wheezes, rubs, or rhonchi.

Cardiovascular: S1 and S2 heard but no S3 or S4. Irregular rate and rhythm noted. There are however no murmurs, gallops, or rubs on auscultation.

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Gastrointestinal: The abdomen is soft and non-tender and is not distended. Bowel sounds are present and there is no rebound tenderness or guarding. On palpation, there are no masses detectable and no hepatosplenomegally. Case Analysis Discussion Paper

Musculoskeletal and Extremities: There is muscle weakness and a limited range of motion around the major joints. There is also some degree of muscle tenderness. On the lower aspect of the right lower extremity, there is a purulent sore on the lateral aspect of the ankle measuring about 2 cm in diameter.  

Diagnostic Tests: These are the tests that will aid in making the correct diagnosis as well as in establishing possible differential diagnoses. They will include:

  1. Laboratory estimation of the cardiac enzyme or biomarker of troponin which is given out by necrotic myocardial tissue. This test has got superior sensitivity and is the one recommended by the clinical practice guidelines of the American College of Cardiology and the American Heart Association (ACC/AHA). It is also very accurate and reliable in the detection of both myocardial ischemia and infarction (Arnett et al., 2019).
  2. A comprehensive metabolic panel. This will give n indication into what may be going wrong with the pathophysiologic process in the heart or the gastrointestinal system (Hammer & McPhee, 2018).
  3. Echocardiogram: This is a test that will reveal in a very specific and sensitive way whether the myocardium is functioning as it should or not (Arnett et al., 2019; Hammer & McPhee, 2018). It is an example of the use of a health IT resource in arriving at a diagnosis.
  4. Electrocardiogram (ECG): The ECG will show if there are any abnormalities of contraction of the heart or abnormalities in rhythm (arrhythmia). This is another use of a health IT resource for diagnosis.
  5. Chest X-ray: A chest X-ray will show if the heart is enlarged or if there is a hiatal hernia (Hammer & McPhee, 2018).
  6. Coronary CT angiography: This specific test will be able to show if there is narrowing of the coronary arteries that supply the heart muscle hence the ischemia (Arnett et al., 2019; Hammer & McPhee, 2018).
  7. Lipid profile: With the history of hyperlipidemia, it would help to know the current levels of low-density lipoprotein cholesterol in his blood which could explain an acute MI (Arnett et al., 2019; Hammer & McPhee, 2018).
  8. Thyroid function tests: He has a history of hypothyroidism and so this test ha to be done to get the latest figures for proper management (Hammer & McPhee, 2018).
  9. Scintigraphy or gastric emptying study: This is a specific test to rule out gastroparesis (Hammer & McPhee, 2018).
  10. Upper GIT endoscopy: This test will help rule out gastroesophageal reflux disease or GERD (Hammer & McPhee, 2018).
  11. Complete blood count (CBC): In a patient such as this one, baseline parameters of the blood must be established by way of a CBC. Also, it is important to know whether there is leucocytosis and to what extent because the patient’s sore is infected and he has a fever (Hammer & McPhee, 2018). Case Analysis Discussion Paper

Assessment

From the above history and physical examination, the following are the most likely differential diagnoses for patient J.S.’s chest pain. The first one is the most likely followed by the rest:

  1. Angina pectoris: It is the most likely diagnosis for patient J.S. this is because he suffers from hyperlipidemia and is also hypertensive. These two chronic conditions predispose him to atherosclerosis that progressively narrows the lumen of the coronary arteries. Gradually, the volume of blood that reaches the myocardium lessens and the myocardium suffers ischemia that manifests as chest pain (Arnett et al., 2019; Hammer & McPhee, 2018).
  2. Myocardial infarction: This will be the more serious consequence of the atherosclerosis described above. It is a medical emergency and will mean that the chest pain is indicative of an already necrotic section of the myocardium (Arnett et al., 2019; Hammer & McPhee, 2018).
  • Gastroesophageal reflux disease (GERD): This diagnosis is possible because persons who are obese are known to suffer from it. It is a reflux of gastric contents that contain hydrochloric acid into the esophagus. This corrodes the lining of the gullet causing the burning chest pain (Hammer & McPhee, 2018 De Bortoli et al., 2013).
  1. Hiatal hernia: A hiatal hernia is also common among overweight and obese individuals and will present with heartburn or burning chest pain (Hammer & McPhee, 2018).
  2. Gastroparesis: Gastroparesis is the weakness of the muscles of gastric motility giving rise to stagnation of gastric contents that then flow back to the esophagus causing heart burn (Hammer & McPhee, 2018).

Plan

The pharmacologic interventions appropriate for each differential diagnosis are as follows:

  1. Angina pectoris: short-acting nitrates, beta blockers and calcium channel antagonists (Katzung, 2018).
  2. MI: acetyl salicylic agent (ASA), beta blockers, and thrombolytic agents (Katzung, 2018).
  • GERD: prokinetic agents, histamine blockers, antacids, and proton ump inhibitors (Katzung, 2018).
  1. Hiatal hernia: proton pump inhibitors (Katzung, 2018).
  2. Gastroparesis: metochlopramide for gastric motility and ondansetron for vomiting (Katzung, 2018). Case Analysis Discussion Paper

References

Arnett, D.K., Blumenthal, R.S., Albert, M.A., Buroker, A.B., Goldberger, Z.D., Hahn, E.J., Himmelfarb, C.D., Khera, A., Lloyd-Jones, D., McEvoy, J.W., Michos, E.D., Miedema, M.D., Muñoz, D., Smith Jr, S.C., Virani, S.S., Williams Sr, K.A., Yeboah, J., & Ziaeian, B. (2019). 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation, 140(11), e596-e646. https://doi.org/10.1161/CIR.0000000000000678

Ball, J., Dains, J.E., Flynn, J.A., Solomon, B.S., & Stewart, R.W. (2019). Seidel’s guide to physical examination: An interprofessional approach, 9th ed. Elsevier.

Bickley, L.S. (2017). Bates’ guide to physical examination and history taking, 12th ed. Wolters Kluwer.

De Bortoli, N., Martinucci, I., Bellini, M., Savarino, E., Savarino, V., Blandizzi, C., & Marchi, S. (2013). Overlap of functional heartburn and gastroesophageal reflux disease with irritable bowel syndrome. World Journal of Gastroenterology, 19(35), 5787-5797. https://doi.org/10.3748/wjg.v19.i35.5787

Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. McGraw-Hill Education.

Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14th ed. McGraw-Hill Education. Case Analysis Discussion Paper