HISTORY OF PRESENTING ILLNESS:
56 year old female presented to emergency (ER) with the chief presenting complaint of pain in chest which was sudden in onset radiating up to her neck. She also experienced shortness of breath while having chest pain without diaphoresis, vomiting, or nausea. The symptoms subsided on resting. The next day, she started feeling same symptoms while she was walking her dog. She then rushed to the hospital and did not do anything for her pain besides coming here. She does not remember experiencing dizziness, palpitations or dyspnea on exertion. The pain remained same even on moving and had no effect on the body dynamics. She also denies having heartburn or any of its symptoms. She was diagnosed as hypertensive 4 years ago but she never experienced suddenly appearing chest pain or any other heart abnormality.
She does not drink alcohol or smoke cigarettes. She was operated 8 years ago for total abdominal hysterectomy with bilateral salpingo-oophorectomy. She is not currently on hormonal therapy. She is unaware of her blood cholesterol but she has a positive family history for premature coronary artery disease (CAD).
PAST MEDICAL HISTORY:
Known case of hypertension since 4 years, prescribed an unknown anti-hypertensive but withdrawn from patient due to drowsiness.
Diagnosed with peptic ulcer disease which resolved after taking H2 receptor blocker.
Allergic to Penicillin and developed hives long time ago.
PAST SURGICAL HISTORY:
Total abdominal Hysterectomy (TAH) with bilateral salpingo-oophorectomy (BSO) almost 8 years ago for removal of uterine fibroids.
Bunionectomy done 4 years ago
FAMILY HISTORY:
Mother is alive and well and her age is 79.
Father deceased. Died of a heart attack and she does not have siblings.
SOCIAL HISTORY:
Tobacco use - negative.
Prescription or illegal drugs – negative
Ibuprofen for headache and backache only.
SYSTEMIC REVIEW:
HEENT:
No active complaint.
Cardiovascular:
Discussed in HPI
Gastrointestinal:
Epigastric pain twice a month mostly burning in nature. Otherwise gastrointestinal system is insignificant.
Genitourinary:
No active complaint.
Musculoskeletal:
Lower back pain after strenuous work once a month: Dull achingpain in nature which subsides on taking NSAIDs.
Neurological:
No active complaint.
Physical Examination:
VITAL SIGNS:
Blood Pressure: 167/99 mm Hg
Pulse: 91 beats/minute
Respiratory Rate: 22 breaths/minute
Temperature: 37.2ºC
O: She appears wee oriented, alert and co-operative.
Skin: Texture and appearance both are normal with normal temperature.
HEENT: pupils normally dilating with intact reflexes. On fundoscopic examination, normal vasculature visualized.
Tympanic membranes are intact.
Nasal mucosa normally appearing with intact orpharynx
Neck: no adenopathy, trachea in midline with no swelling over thyroid. Normal JVP.
Chest: Clear to auscultation lungs with basal crackles bilaterally. Rest of the examination was insignificant.
Abdomen: symmetrical, scaphoid with inverted centrally placed umbilicus. No visceromegaly.
Extremities: cyanosis, edema, clubbing are not noted. Peripheral pulses were all symmetrically palpable.
Genital/Rectal: Normal sphincter tone with no gross lesion or mass.
Neurological: cranial nerve examination was normal with intact motor and sensory examination of the CNS. Reflexes are normal with symmetrical presentation.
Provisional Diagnosis:
Chest pain with angina pectoris.
MEDICATIONS (Katzung, Masters and Trevor, 2012) :
Aspirin 160 mg STAT
Clopidogrel 300 mg OD
Enoxaparin IV 0.5mg/kg for 48 hours
Captopril 25mg BD
Bisoprolol 5mg OD
Amlodipine 5mg BD
Lasix 40mg OD
Nitroglycerin SOS
Omeprazole 20mg BD
FOLLOW UP CARE PLAN:
Patient compliance should be checked (Stegman, Miller et al., 1987)
Monitoring of patient for chest pain suggesting myocardial infarction
Platelet inhibitors like aspirin should be initiated then moving on to analgesia
Strict monitoring of cholesterol and administration of lipid lowering agents along with introduction of DASH diet. (Papadakis and McPhee, 2015)
Scheduling of cardiac catheterization if necessary.
Administration of diuretics for dyspnea (Kallet, 2007)
Appropriate labwork that includes BUN/Creatinine and electrolytes and baselines EKG.
References
Kallet, R. (2007). The role of inhaled opioids and furosemide for the treatment of dyspnea. Respiratory Care, 52(7), 900-910.
Katzung, B., Masters, S., & Trevor, A. (2012). Basic & clinical pharmacology. New York: McGraw-Hill Medical.
Papadakis, M., & McPhee, S. (2015). Current Medical Diagnosis & Treatment 2015 (54th ed.). New York: McGraw-Hill Education/Medical.
Stegman, M. et al., (1987). Myocardial infarction survival: how important are patients' attitudes and adherence behaviors?. American Journal of Preventive Medicine, 3(3), 147-151.
