Let's study Medical English. CHEST PAIN.P3
Diagnostic Considerations
List your diagnostic considerations in order of importance ad explain your rationale.
Angina. This woman has stress‐induced non‐exertional chest pain. Recent evidence shows that women present with more subtle symptoms of cardiovascular disease. She has cardiac risk factors of hypertension, past smoking, preeclampsia, and family history.
Panic attack. She had stress related symptoms and flashbacks to the recent death of her father in a car accident. She has suggestive anxiety, chest pain, and diaphoresis.
GERD. Her alcohol intake has recently increased. She has some reflux symptoms but her symptoms are not triggered by meals and she does not report heartburn.
Musculoskeletal chest wall pain. There is no history of chest pain triggered by movement of the upper torso or related exercise, and no notation of chest wall tenderness.
Dissecting aortic aneurysm. There is no asymmetry of blood pressures noted and no history of pain shooting into the neck, up the side of the head, or into the back.
Diagnostic Workup
List 5 next steps in your diagnostic workup.
EKG. About 80% of patients with an acute MI have an initial EKG that shows evidence of new infraction or ischemia, if read correctly. However, among patients mistakenly discharged from the emergency department, up to 50% have normal or non‐diagnostic EKG findings.
Stress echo. This is the test of choice for women with atypical chest pain. The echocardiography stress test has a sensitivity of 90% and specificity of 79% for women, and 85% and 96% for men.
Consider a trial of a proton pump inhibitor for 4‐6 weeks for possible GERD.
Chest x‐ray may be helpful to look for widened mediastinum, which can be evidence of aortic dissection.
Behavioral therapy—to learn management strategies for anxiety and panic disorder.
Summary
In sum, this is a 50-year-old school counselor with three episodes of left substernal chest pain over the prior two weeks, rated 5 to 10 in intensity, with associated sweating and shortness of breath.
The first episode was precipitated by reading about a car crash, the cause of her father’s recent death. The patient had hypertension during pregnancy and a brief smoking history in her 20s.
There is a strong family history of coronary artery disease. Her mother died of a myocardial infarction at age 62 and her brother had a coronary bypass at age 48.
There is no history of diabetes. Her physical examination is unremarkable except for her blood pressure of 150 over 95.
The differential diagnosis includes angina, especially suspect due to her symptoms, history of hypertension during pregnancy, and family history. It also includes panic attack, GERD, musculoskeletal chest pain, and dissecting aortic aneurysm.
The diagnostic workup includes an EKG, stress echo, trial of a PPI, chest x‐ray, and behavioral therapy.
Sài gòn 18/2/2023
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