CLINICAL REASONING
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Transcript of CLINICAL REASONING
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CLINICAL REASONING
DR MOHSEN ELKHAYAT
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CASE 1
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Identifiers and Chief Complaint
• 45 year old woman referred for evaluation of noncardiac chest pain
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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.
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• 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.
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• Previous Medical Diagnoses, Hospitalizations, and Operations:
• Hypertension
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• Medications: • Atenolol• Nitroglycerin sublingual prn
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• Habits and Social History: • No tobacco, alcohol or illicit drug use.• She is divorced and has 3 grown children. She
works as a housekeeper.
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• Family History: • No relevant family history of serious diseases
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• 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
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• 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
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• No endoscopy was performed on this patient• No imaging was obtained on this patient.
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• The diagnosis based on the preceding history, physical examination, laboratory data, and prior cardiac evaluation is:
• Noncardiac chest pain
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• Consider the following questions about the best management of this patient's problems
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• 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
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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
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• 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
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• 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
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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
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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
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Lab studies
• UG, negative• CBC normal• Chem normal, glc 81• LFT’s normal• TFT’s normal, HbA1C 5.3, ESR 2
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What next?
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What next?
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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.
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Follow-Up • What is other investigation needed• Any differential • What is your management