CLINICAL REASONING

DR MOHSEN ELKHAYAT

CASE 1

Identifiers and Chief Complaint

• 45 year old woman referred for evaluation of noncardiac chest pain

History of the Present Illness:

• She has been having chest pain for the past 1-2 years. She has had multiple hospitalizations for chest pain and has had extensive cardiac workup, including a cardiac catherization which did not revealed any significant coronary artery disease. She states that the pain is pressure-like, retrosternal, and without radiation.

• Pain occurs both at rest and with activities, lasting up to 15-20 minutes, and is usually relieved with sublingual nitroglycerin. She denies any associated nausea, vomiting, dyspnea, and diaphoresis. She admits to occasional heartburn but denies any odynophagia or dysphagia.

• Previous Medical Diagnoses, Hospitalizations, and Operations:

• Hypertension

• Medications: • Atenolol• Nitroglycerin sublingual prn

• Habits and Social History: • No tobacco, alcohol or illicit drug use.• She is divorced and has 3 grown children. She

works as a housekeeper.

• Family History: • No relevant family history of serious diseases

• BP: 128/72 HR: 74 RR: 16 T: 37.1 Weight: 88kg Height: 167

• General: normal Skin: normal Extremities: normal HEENT: normal Lungs: normal Heart: normal rhythm and heart sounds; no murmurs, rubs or gallops Abdomen: soft, no tenderness, no organomegaly, no mass Rectal: normal Neurologic: normal

• Hgb (gm/dL) 13.7

• Hct (%) 43

• WBC(x109/L) 7.8

• TProt (gm/dL) 8.3

• Alb (gm/dL) 4.0

• TBili (mg/dL) 0.8

• Glu (mg/dL) 102

• Urea (mg/dL) 17

• Creat ( mg/dL) 0.9

• Ca (mg/dL) 9.3

• No endoscopy was performed on this patient• No imaging was obtained on this patient.

• The diagnosis based on the preceding history, physical examination, laboratory data, and prior cardiac evaluation is:

• Noncardiac chest pain

• Consider the following questions about the best management of this patient's problems

• 1. What is the differential diagnosis of noncardiac chest pain?

• 2. What is the pathophysiology of noncardiac chest pain?

• 3. How can you evaluate a case of noncardiac chest pain?

• How can you treat this case

Case 2: 25 yo with vomiting & wt loss

• 25 years old female presents to OPD and complains of vomiting and weight loss

• Started vomiting 12-18 months prior• Intermittent, but worse after meals– Initially unrelated to specific foods

• Progressive– Now she is waking up at night to vomit– Everything she eats “comes back up”

• Partially digested or undigested food• Seen at Outpatient and treated for acid reflux,

but now can’t keep the medicine down

• No hemetemesis, no diarrhea or constipation• No fever or chills• No odynophagia• No abdominal pain• She is having chest pain– Due to food getting stuck in her chest

More History

• Vaginal delivery 4 months prior– Baby is healthy– No complications during pregnancy and symptoms

improved somewhat• Currently taking no medications• Smokes about 1 pack per week• No alcohol or illicit drug use• Father had a stroke at 31, other family

members with diabetes and hypertension

Physical Exam• VITAL SIGNS: BP 140/94, pulse 76, respirations 18, AF• Weight: 85 initially, now 71• GENERAL: NAD but anxious• HEENT: Moist membranes, no lesions; no dental

erosions• NECK: no LAD, thyromegaly or palpable masses• ABD: mild epigastric tenderness but soft and without

rebound or guarding, had redundant skin

Lab studies

• UG, negative• CBC normal• Chem normal, glc 81• LFT’s normal• TFT’s normal, HbA1C 5.3, ESR 2

What next?

What next?

Imaging

• Ba swallow– no passage of barium into the stomach. The distal

esophagus has a smooth tapered appearance with “beak-like” appearance. No irregularity is identified in this region to suggest tumor. At 5 minutes, the barium column in the esophagus remained unchanged at the level of the clavicles and there was minimal passage of contrast into the stomach.

Follow-Up • What is other investigation needed• Any differential • What is your management