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CLINICAL REASONING

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:.

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CLINICAL REASONING

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  1. CLINICAL REASONING DR MOHSEN ELKHAYAT

  2. CASE 1

  3. Identifiers and Chief Complaint • 45 year old woman referred for evaluation of noncardiac chest pain

  4. 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.

  5. 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.

  6. Previous Medical Diagnoses, Hospitalizations, and Operations: • Hypertension

  7. Medications: • Atenolol • Nitroglycerin sublingual prn

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

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

  10. BP: 128/72 HR: 74 RR: 16 T: 37.1Weight: 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

  11. 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

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

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

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

  15. 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

  16. 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

  17. Progressive Now she is waking up at night to vomit Everything she eats “comes back up” Partially digested or undigested food Seen at Outpatientand treated for acid reflux, but now can’t keep the medicine down

  18. 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

  19. 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

  20. 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

  21. Lab studies UG, negative CBC normal Chem normal, glc 81 LFT’s normal TFT’s normal, HbA1C 5.3, ESR 2

  22. What next?

  23. What next?

  24. 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.

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

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