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2024 Comprehensive Case Study: 49-Year-Old Patient with Intermittent Squeezing Chest Pain (CLASS 6512) | iHuman Case Analysis Week #7
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Patient Name: Florence Blackman Patient Age: 49 - year-old
Chief complaint: Florence Blackman is a 49-year-old female with a past medical history significant for hypertension and hypercholesterolemia who presents today for complaints of “intermittent squeezing chest pain”.
HOPI: The patient is a 49-year-old female who presents to the clinic with complaints of intermittent midsternal chest pain that started two weeks ago. She describes it as a moderate 6/10 “squeezing” pain which radiates to the left arm and is worse with exertion. The patient also reports dyspnea associated with the episodes of chest pain and worsening pain in the cold weather. The pain and shortness of breath has a sudden onset and is only alleviated by rest which sometimes interferes with her ability to do cross-country skiing in the winter. Patient denies any fatigue, fever, chills, nausea, vomiting, sleeplessness, or abdominal discomfort. She denies any allergies or use of over-the-counter prescription medications or herbal supplements to help with symptoms. She reports a past medical history of hypertension for which she is taking 12.5 mg of hydrochlorothiazide daily and hypercholesterolemia which she is attempting to manage with diet changes. The family includes stroke and coronary artery disease. The physical examination is normal, except for a BMI of 25.5. History: Medical:
Surgical/Hospitalizations:
line at the fifth intercostal space. There is no jugular vein distention and patient has normal jugular venous pressure. No abnormal pulsations and/or bruits. Gastrointestinal: Abdomen is nondistended and there are no masses observed. Soft/ non-tender to palpation and tympanic to percussion with dullness over solid viscera. Bowel sounds are present and normoactive in all four quadrants. Patient’s symptoms are not reproduced when applying epigastric pressure. Musculoskeletal: All extremities are symmetric with no deformities present. No localized pain or tenderness. Full range of motion of upper and lower extremities. Strength test is 5/5 bilaterally. Peripheral vascular: No peripheral edema of lower or upper extremities and are warm and dry. Radial pulses are 2+ bilaterally and capillary refill is less than 3 seconds for all extremities. No cyanosis or clubbing in the finger or toenails. Laboratory data :
Primary Differential Dx: Stable Angina related to coronary artery disease a. Inclusion Criteria: o History of hypercholesterolemia, hypertension, smoking, and overweight status o Family history of cardiac disease o Abnormal serum lipid profile o Normal chest X-ray o Chest pain and shortness of breath with exertion which is relieved with rest b. Exclusion Criteria: o Cardiac stress test showing ST depression in the inferior lead may warrant further testing with an angiography, but patient is refusing Differentials for Primary Problem Alternative DDX: Myocardial Infarction c. Inclusion Criteria: o Chest pain which radiates to the left arm with associated shortness of breath o History of cardiac disease in the family o Patient’s past medical history of hypertension and hypercholesterolemia o Abnormal cardiac stress test d. Exclusion Criteria: o Pain is intermittent and relieved with rest vs. with an MI it would be a constant pain o Troponin levels were normal
o Normal ECG and chest X-ray was normal (no evidence of cardiomegaly) o Normal TTE Alternative DDX: Costochondritis a. Inclusion Criteria: o Intermittent chest pain and dyspnea on exertion b. Exclusion Criteria: o Pain and shortness of breath are relieved with rest o No associated costochondral pain or tenderness upon palpation
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