deborah212 Posted December 26, 2011 Share Posted December 26, 2011 68 yo female with a history of CAD with admission complaint of chest pain. Triage Vitals: T 97.3 P103 BP 171/90 RR 20 O2 Sat 98% on RA. You are told by the ED that that EKG is ok and "not unstable angina." Patient has already received ASA 325 mg. I will tell you that the patient is stable. Her history will give you the diagnosis- and be confirmed by other things. What do you want to know? Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted December 26, 2011 Administrator Share Posted December 26, 2011 How did it come on, gradually or all at once? What makes it better or worse? Please point with one finger where it hurts the worst. Does it radiate to anywhere else? Is it continuous or intermittent? Has it been getting better/worse, or stayed stable? If there are multiple episodes, when do they happen and how long do they last? How long has it been since the first onset of this pain? How would you characterize this pain: burning, crushing, tearing, sharp/stabbing, aching...? (in other words run through OLDCARTES, OPQRST, or whatever pain mnemonic you use) Past medical history: CAD/past MI, DM, HTN, HLP, CVA, asthma...? Other chronic problems? Psych? Surgeries: How many and which? Medications: What is she prescribed, and "why?" if there are multiple possible indications for her meds. Family history: What first degree relatives have died? What ages and causes? Are any of them left alive living with chronic medical problems? Social history: smoking, ETOH, IVDU, past hazardous employment/environmental exposure. ROS, focusing on Cardiac, Pulm, GI, M/S, vascular, psych, but hitting the high points of everything. I'll review past chart notes and labs/imaging (if any) once we decide what, if anything, to order. Link to comment Share on other sites More sharing options...
deborah212 Posted December 26, 2011 Author Share Posted December 26, 2011 How did it come on, gradually or all at once? What makes it better or worse? Please point with one finger where it hurts the worst. Does it radiate to anywhere else? Is it continuous or intermittent? Has it been getting better/worse, or stayed stable? If there are multiple episodes, when do they happen and how long do they last? How long has it been since the first onset of this pain? How would you characterize this pain: burning, crushing, tearing, sharp/stabbing, aching...? Chest pain began about a week ago on the right side of her chest. She describes it as a "pressure" that radiates to her right cheek and down her right arm. The pain has been escalating but only occurs at night. Worse with lying flat. Sitting up makes it completely go away. Past medical history: CAD/past MI, DM, HTN, HLP, CVA, asthma...? Other chronic problems? Psych? HTN CAD s/p MI 5 years ago. Medically managed. Happened while visiting family in Columbia s/p chole No other medical history Medications: What is she prescribed, and "why?" if there are multiple possible indications for her meds. Atenolol 50mg Lisinopril 10mg Simvastatin 20 mg Asa 81mg Did not take meds this am Family history: What first degree relatives have died? What ages and causes? Are any of them left alive living with chronic medical problems? Mother with DMII. Some other relatives with "heart issues." Social history: smoking, ETOH, IVDU, past hazardous employment/environmental exposure. 20 year pack history of smoking. No alcohol or IVDU. No occupational exposures. ROS, focusing on Cardiac, Pulm, GI, M/S, vascular, psych, but hitting the high points of everything. Ok- so I'm going to let you get away with this because I am short on time. HEENT: Mild headache for several days. Never had headache before. No visual changes. Face feels a bit puffy. CV: Denies orthopnea but had new PND several times per night. Pulm: Increasing shortness of breath with exertion for past month. New non-productive cough. No hemoptysis. Abd: No diarrhea or abdominal pain. Ext: Denies swelling Gen: No weight loss, night sweats, fatigue Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted December 26, 2011 Administrator Share Posted December 26, 2011 Thanks. OK, so my DDx so far is looking very much like CHF, with the history+PND. Others to consider include unstable angina (I know they said it wasn't. Trust but verify), NSTEMI, COPD, Valvular disease, DM II. In this scenario, I'm a hospitalist, not an ED practitioner, right? Follow up to history: Let's dig into the cough a bit more--Has she had a smoker's cough before? How long has she been on Lisinopril? Physical exam: Full standard, with special focus on... * HEENT. Look for hypertensive changes in the retina--AV nicking, papilledema, copper wiring, etc. * Cardio. Listen well for murmurs or extra heart sounds which might indicate fluid overload or valvular issues, assuming RRR. * Pulm. All lung fields--diminished/faint breath sounds secondary to COPD? Wet/coarse? Consolidations? * Vascular. JVD? Listen for carotid bruits. Extremity pulses equal and arrive together? * Extremities. Edema, foot sensation, strength x4, full resisted ROM functioning in upper extremities to r/o m/s causes for the pain. * Chest. Palpate ribcage--any TTP indicating rib soreness? * Abd. TTP? bowel sounds? * Neuro. Basic CVA eval, Romberg, DTRs. * Psych. Anxiety/depression screen. * Skin. Turgor, rashes Skipping ahead to labs, if the ED hasn't already ordered these, I want (or want to see the results if already ordered/done...) * 12 lead * CXR, A/P+Lateral * Troponins, CK-MB, CBC+diff, BMP * UA+c/s if indicated Link to comment Share on other sites More sharing options...
Just Steve Posted December 26, 2011 Share Posted December 26, 2011 I see she's currently afebrile but has she had any fevers? Her visit to Columbia...long drive/flight?...am trying to dig into PE risk factors a bit to see if it's worth adding to the Ddx I like where Rev is headed but wouldn't mind seeing pleuritis added to the Ddx. Link to comment Share on other sites More sharing options...
deborah212 Posted December 26, 2011 Author Share Posted December 26, 2011 I see she's currently afebrile but has she had any fevers? Her visit to Columbia...long drive/flight? Hasn't been to Columbia since 5 years ago. No fevers. Let's dig into the cough a bit more--Has she had a smoker's cough before? How long has she been on Lisinopril? Cough started around the same time as her dyspnea a couple of weeks ago. She isn't bringing anything up but feels "hoarse." Has been on lisinopril for the past 5 years (good thought!) Exam: BP 140/80 (Given home meds in ED) HR 84 RR 18 O2 sat 97% on RA Gen: Well appearing female, sitting on stretcher, conversive HEENT: PERRLA. OP clear. EOMI. MMM. No fundoscopic exam done. Face doesn't seem to be edematous but unclear baseline. Neck: JVP to angle of the jaw. No palpable lymphadenopathy. CV: S1 + S2, S4 RRR no r/m/g Pulm: Clear to ausclutation Abd: +BS. Soft/NT. No bruits Ext: Vessels in right arm are prominent. No gross edema of upper or lower extremities Neuro: CN II-XII grossly intact. 5/5 strength against resistance of upper and lower extremities * 12 lead * CXR, A/P+Lateral * Troponins, CK-MB, CBC+diff, BMP * UA+c/s if indicated EKG: NSR at 80. LVH with repolarization abnormality. Pathologic qwaves in inferior leads. No ST changes. CXR: Fullness in the right upper lobe. Radiologist lists malignancy vs inflammatory vs infectious differential Na 133, K 4.0, Cl 108, CO2 22, BUN 10, Cr 0.76, Glucose 92 WBC 5.8, HCT 42, Platelets 205 Normal Differential Cardiac enzymes negative UA: Negative Link to comment Share on other sites More sharing options...
flyingsquirrel Posted December 26, 2011 Share Posted December 26, 2011 The fact that the pain is worse at night/when lying down and improves with sitting, plus the cough and SOB makes me want to put pericarditis near the top of the differential list...but I won't be a PA student for a couple more months so I'll go back to lurking now... Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted December 26, 2011 Administrator Share Posted December 26, 2011 * With a normal white count, differential, and afebrile, I'm going to want to r/o cancer before I go chasing infection. * I don't see any ECG findings that would make me suspect pericarditis, and I'm not familiar with pericarditis being completely relieved by positioning. * Inflammation is always a possibility, but the history just doesn't sound like PE to me, so I'm going to go with... Superior vena cava syndrome, +/- pancoast syndrome, secondary to primary lung malignancy, most likely SCLC. She needs a CT scan with contrast and an oncology consult. (I can't believe I left this out of my first differential given the 20 pack/years) Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted December 27, 2011 Share Posted December 27, 2011 Are there any side-to-side differences in pulses or BP? Any correlation between oral intake, esp larger meals, and pressure? Any Hx of GERD? Any numbness or tingling in her R arm? Any muscle pain on palpation? Does she use a computer with a mouse extensively? I don't think any of these point to things high on the differential list, but quick and easy things to lessen likelihood of aortic aneurisms, GERD, and musculoskeletal causes. Link to comment Share on other sites More sharing options...
deborah212 Posted December 27, 2011 Author Share Posted December 27, 2011 The fact that the pain is worse at night/when lying down and improves with sitting, plus the cough and SOB makes me want to put pericarditis near the top of the differential list Good thought. Typically, pericardial pain is relieved by leaning forward but patients don't read the textbooks... Are there any side-to-side differences in pulses or BP? No significant difference but ALWAYS a good idea to think about dissection. Any correlation between oral intake, esp larger meals, and pressure? Any Hx of GERD? Any numbness or tingling in her R arm? Any muscle pain on palpation? Does she use a computer with a mouse extensively? No to all. Superior vena cava syndrome Yes! This diagnosis was made by history, particularly review of systems when the patient admitted to increasing positional headache, facial swelling, and hoarseness, and supported by physical exam (JVD, engorged right arm veins). CTA: Right spiculated lung mass with mediastinal mets, one of which encased the SVC with near complete occlusion but significant collaterals. While a medical oncology consult is important, the critical input comes from the radiation oncologist as to whether emergent irradiation is required. In this case, it wasn't. Link to comment Share on other sites More sharing options...
andersenpa Posted December 27, 2011 Share Posted December 27, 2011 The SVC (usually) drains both the RUE and LUE -Why was only the right side affected in this case? -What is the anomoly where the LUE would not drain into the SVC? Link to comment Share on other sites More sharing options...
jesscbv Posted December 28, 2011 Share Posted December 28, 2011 The SVC (usually) drains both the RUE and LUE-Why was only the right side affected in this case? -What is the anomoly where the LUE would not drain into the SVC? Could it have been because of the "significant collaterals?" Perhaps left collateralized better than right? Link to comment Share on other sites More sharing options...
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