B.S.
DOB: 12/25/1992
GENDER: Female
Race: Caucasian
RELIGION: Catholic
MARITAL STATUS: Single
OCCUPATION: College Student
CHIEF COMPLAINT: “I am scared. I feel like I can’t catch my breath and my chest hurts.”
Differential Diagnosis: There are a number of differential diagnoses for these presenting symptoms. The major ones will be explored here.
Possible Diagnosis
Myocardial infarction (MI), angina, acute coronary syndrome
Prodromal symptoms include fatigue, chest discomfort, or malaise in the days before the MI. A typical STEMI may occur without warning. Onset is not directly associated with severe exertion but concomitant with exertion. Other symptoms include: anxiety, light-headedness with or without syncope, nausea or indigestion, cough, diaphoresis, and/or wheezing.
Physical Exam: Physical symptoms can be variable. The typical chest pain of an acute MI is intense and continuous for 30-60 minutes, retrosternal, and may radiate up to the neck, shoulder, and jaw and down to the ulnar aspect of the left arm and may be described as burning, squeezing, aching, or sharp. Sometimes the main symptom is epigastric with indigestion. Hypertension or hypotension may be present depending on the foci of the MI. Acute valvular dysfunction may be present. Other symptoms such as confusion, anxiety, a sense of impending doom, profound restlessness, diaphoresis, weakness, presyncope, hiccupping (which reflects an irritation of the diaphragm or phrenic nerve), vomiting, and palpitations may be present. Atypical presentations may include abdominal discomfort, jaw pain, altered mental status (more often in elderly patients) or atypical chest pain. Nearly half of MIs are clinically silent as they are not associated with the symptoms described above and may go unrecognized.
Diagnostic Testing: Blood pressure monitoring, (ECG/EKG), cardiac imaging, cardiac catherization, coronary artery calcium scoring, cardiac biomarkers/enzymes, troponin levels, creatine kinase levels, myoglobin levels, check kidney functions and electrolyte levels, evaluate medications.
Atrial fibrillation (AF)
History: Clinical presentation can also be variable from asymptomatic atrial fibrillation with rapid ventricular response to cardiogenic shock or CVA. The majority of AF episodes are asymptomatic. Three patterns of AF: paroxysmal AF — terminate spontaneously within seven days but the majority last less than 24 hours; persistent AF – last more than seven days and often require pharmacologic or electrical intervention; Permanent AF – persisted for greater than one year.
Physical Exam: An AF dx is based on the physical finding of an irregular heart rhythm.
Diagnostic Testing: A 12-lead ECG would be appropriate.
Atrial flutter
History: Palpitations, “fluttering” sensation in the chest, shortness of breath, anxiety, general weakness.
Physical Examination: Typically a macro reentrant arrhythmia with atrial rates of between 240 and 400 beats per minute.
Diagnostic Testing: ECG
Mitral Valve Prolapse (MVP)
History: Symptomatic MVP is divided into three categories: symptoms related to autonomic dysfunction, symptoms related to the progression of mitral regurgitation; and symptoms that occur as a consequence of some other complication such as a CVA or other complication. Symptoms related to autonomic dysfunction (usually congenital) include anxiety, panic attacks, fatigue, arrhythmia, atypical chest pain, orthostasis, syncope, and/or neuropsychiatric symptoms.
Physical Exam: MVP classic auscultatory finding is a mid-to-late systolic click and/or murmur.
Diagnostic Testing: Physical examination, echocardiography.
Acute respiratory distress syndrome (ARDS).
History: Characterized by the development of acute hypoxemia and dyspnea typically 12-48 hours following some event (although it may be even longer after the event). Events such as trauma, sepsis, drug overdose, massive transfusion, acute pancreatitis, or aspiration. The event may be obvious or it may be difficult to identify depending on the case.
Physical Exam: Often presents with nonspecific symptoms such tachypnea, tachycardia, and the need for a high fraction of inspired oxygen (FIO2) in order to maintain oxygen saturation. May be febrile or hypothermic.
Examination of the lungs may reveal bilateral rales. If ARDS occurs as a result of sepsis there may be hypotension and peripheral vasoconstriction with cold extremities and possibly cyanosis of the lips and nail beds. If sepsis is not readily apparent pay attention for signs of lung consolidation or findings consistent with an acute abdomen. Any recent wounds drain sites, and decubitus ulcers should be examined for infection. Check for subcutaneous air, a manifestation of infection or barotrauma.
Diagnostic Testing: ADRS is a clinical diagnosis so an acute onset of symptoms is noted, chest radiograph, hemodynamic monitoring, and/or bronchoscopy.
Pulmonary Embolism (PE)
History: Classic presentation is sudden onset of pleuritic chest pains, shortness of breath, and hypoxia. However, many do not display these symptoms at often people who died from PE complained of nagging symptoms for weeks before their death.
Physical Exam: Nonspecific clinical signs and symptoms. Sometimes dyspnea, tachypnea, or chest pain.
Diagnostic Testing: Can be lengthy. Typically pulse oximeter with mild exertion (walking) will identify suspect cases.
Hyperthyroidism
History: Anxiety, increased perspiration, heat intolerance, hyperactivity, tremor, palpitations, unexplained weight loss, and oligomenorrhea.
Physical Exam: Hyperactivity; atrial arrhythmia or tachycardia; systolic hypertension; the presence of warm, moist, smooth skin; lid lag; tremor; sometimes muscle weakness.
Diagnostic Testing: TSH and thyroid hormone levels, scintigraphy if needed.
Diabetes
History: Polydipsia, polyuria, and polyphagia, lassitude, nausea, and blurred vision.
Physical Exam: Polyuria and associated complaints of nocturnal enuresis, thirst, complaints of weakness or fatigue, muscle cramps, and blurred vision.
Diagnostic Testing: Plasma glucose levels, hemoglobin A1c, fructosamine levels, WBC.
Seizure disorder (Epilepsy)
History: Recurrent blackouts, staring episodes, frequent lapses of concentration, missed periods of time.
Physical Exam: Information gleaned from patient concerning auras, preservation of consciousness, and postictal states.
Diagnostic Testing: Must perform two imaging studies: a neuroimaging evaluation (MRI or CT) and an EEG.
Drug or alcohol intoxication or withdrawal
Caffeine intoxication. Medication side effects.
History: Repeated use or intermittent use of drugs or alcohol to cope or escape from stress.
Physical Exam: Slurring words, balance difficulties, hyper or hypoactivity, over or underarousal, drowsiness, autonomic signs, nausea.
Diagnostic Testing: Urinalysis, chemistry panel analysis. Cardiac markers, measurement of prothrombin time, or toxicology screening may be indicated.
Psychiatric disorders
History: The history will depend on the specific disorder in question. Panic attacks are associated with a number of psychiatric disorders including panic disorder, obsessive compulsive disorder, schizophrenia, bipolar disorder, major depressive disorder, posttraumatic stress disorder, phobic disorders, and somatization disorder.
Physical Exam: Interview with the patient. Look for signs of psychosis (loose associations, delusions or hallucinations), mania (pressured speech, hyperactivity), depression (decreased affect, amotivation, slowed responses).
Diagnostic Testing: Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I).
History of Present Illness:
B.S. is a 19-year-old Caucasian female who presents to the university health center with CC “I am scared. I feel like I can’t catch my breath and I have chest pain.” States that she started to feel nervous about 10-15 minutes ago. Her pulse then started racing and she experienced moderate chest pain ( 6/10 on pain scale). She then started to feel short of breath. She stated she” felt like she couldn’t get air in or out, she started having chest pain and her heart felt as though it was going to jump out of her chest.” She stated she felt as though she was” going to lose control.” Prior to” feeling a little nervous “she was sitting in the library studying for her chemical engineering final that is due to take place tomorrow morning. She stated she has never had any breathing difficulties or chest pain in the past. She stated that “her heart does race right before she starts her exams” but it has “not stopped her from taking exams and usually resolves after she answers a few questions. She admits to “feeling a sense of doom.”
While sitting in the waiting room she was advised by another student to breathe in through her nose and out through her mouth slowly. She reports that after doing so for approximately two minutes she had some relieve of her symptoms and was able to breathe normally. She still feels a little faint and scared. She stated that she still has mild chest pain (3/10). Denies tingling or numbness of the hands and fingers, denies visual disturbances, denies diaphoresis, denies trembling, denies nausea, vomiting or abdominal pain, denies pain radiating to jaw/down left arm. Denies smoking/drug use/no caffeine use. No history of hypertension, MI, hyperlipidemia, asthma, bronchitis, pneumonia, pulmonary emboli, obesity, poor physical conditioning, pneumothorax, foreign body aspiration, phobias. Denies experiencing symptoms like this before. Admits to having obsessive compulsive tendencies.
Past Medical History:
Allergies: NKDA
Medications (prescription): LoOvral I po qd
Medications (OTC): Tylenol ES ii tablets po q 4-6h prn headache. Systane lubricant eye drops I or ii drops OU prn dryness.
Vitamins/Herbs/Supplements: One a Day multivitamin capsule a day
Last Exams: PCP- Family MD 6/7/12 for routine GYN check up and birth control pills, normal exam, LMP current. Optometrist: 5/25/2012 normal exam with no need for glasses. Dentist: about 6 months ago for routine cleaning with no cavities, due to see dentist next month for routine care. Psychologist-PhD as needed to follow up on control of obsessive compulsive tendencies. Dermatologist-MD every 6 months for mole check. Last visit about 3 months ago and normal.
Childhood: Denies measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever. Hospitalizations for acute bronchitis @ 5 yo and appendectomy @ 14 yo.
Surgical: Appendectomy (2005) with no complications, 3 impacted wisdom teeth extracted (2006) with no complications. Lasik surgery OU (2007) with no complications except for onset of dry eye syndrome.
Psychiatric: Admits to obsessive compulsive tendencies but not diagnosed with obsessive compulsive disorder (OCD).
Vaccinations: Tetanus (2006), declines both flu and pneumovax. Has had all childhood required and recommended immunizations on schedule per records. Gardisil, Meningiococcal, Hepatitis C series, chicken pox vaccines completed. 2 step PPD was negative upon admission to university.
Family History:
Father- 50 yo, Hx: HTN
Paternal Grandfather- 72 yo, Hx: HTN, Diabetes
Paternal Grandmother- 70 yo, Hx: Uterine Cancer, HTN
Mother- 48 yo, Hx: Spinal surgery L5S1, HTN
Maternal Grandfather- deceased 68 yo- malignant melanoma
Paternal Grandmother_ 68 yo, Major Depressive Disorder, HTN
1 sister- 17 yo, denies any medical problems
1 brother- 16 yo, asthma, ADHD
Social History:
Pt lives on campus in a suite with three other women. During the summer she lives on campus and works in the genetic research lab. She has lots of friends and parental support. She participates on the track team and in the tutoring program at a local church. She is currently sexually active with one male partner of two years. She does not drink ETOH. She denies use of any tobacco products ever. She denies use of illicit drugs ever. She limits caffeine intake to one 8 oz. caffeinated beverage per day.
EXERCISE HISTORY:
Pt has participated on both high school and collegiate level track teams. She runs approximately 4 miles a day three days a week. She has been doing so for approximately 6 years. She uses the weight room 2 days a week for about 2 years.
NUTRITION:
Healthy, low fat diet
24h recall:
Breakfast- low fat French toast with strawberries and sliced almonds, skim milk
Snack- 2 cups air popped popcorn with small sprinkle of parmesan cheese and 10 dry roasted pecan halves, water
Lunch- tuna salad on spinach with diced apple and low cal mayo, water
Snack- 100 cal. Ice cream bar, water
Dinner- Veggie burger with Portobello mushroom, tomato and onion with multigrain flat bread, water
Ht: 5’8′ Wt: 132 BMI: 19.8
Review of Systems (ROS): Because of the potential psychiatric issues here it would be best to do a full ROS to check for any odd or idiosyncratic complaints in conjunction with ruling out other differentia dx. Patients with psychiatric issues can be quite coy and present as rather normal, so it is best to do a complete formal evaluation and get a solid history. Always record odd or inconsistent symptoms.
Constitutional examination rationale: Looking for recent or unexplained weight loss, night sweats, fatigue/malaise/lethargy, appetite, recent trauma, unexplained falls consistent with thyroid (or other endocrine) dysfunction.
Eye rationale: Looking at visual changes, headache, double vision associated with seizures or diabetes or odd complaints.
Ears, nose, mouth, and throat rationale: Most interested in any nasal discharge, epistaxis, sinus pain, stuffy ears, ear pain, tinnitus, that could be associated with PE, ARDS, odd symptoms (psychiatric?), or seizure activity.
Neurological rationale: Rule out “special senses” (auras), changes in sight, smell, hearing and taste, seizures, fainting, blackouts, paraesthesiae, poor balance, speech problems, loss of consciousness, higher mental function and psychiatric symptoms. Here ruling out seizure disorder, other neurological issues, and psychiatric issues.
Cardiovascular rationale: Obviously the major complaint includes cardio sx, chest pain, shortness of breath, PND, orthopnoea, oedema, palpitations.
Respiratory rationale: Rule out PE and ARDS look at cough, sputum, wheeze, aemoptysis, shortness of breath in conjunction with these.
Gastrointestinal rationale: Any unintentional weight loss, abdominal pain, indigestion, bloating, cramping, anorexia, diarrhea/constipation, obstipation, or haematemesis.
Genitourinary/Urinary rationale: Most interested in incontinence, nocturia, and polyuria in association with diabetes (or odd sx).
Reproductive rationale: Cycle duration and frequency, irregularities, use of other birth control.
Musculoskeletal rationale: Would be most interested in odd or unusual sx.
Integumentary rationale: Any lesions, wounds (self-inflicted), dryness and/or sx associated with thyroid issues.
Endocrine rationale: Look for sx associated with hyperthyroidism preference for cool weather, sweaty, diarrhea, oligomenorrhoea, mood swings, weight loss despite increased appetite, etc. For diabetes: polydipsia, polyuria, or polyphagia. Any other odd sx.
Hematologic/lymphatic rationale: Any anemia, purpura, petechia.
Allergic/immunologic rationale: Any allergic reactions, odd sx, any reaction to contraceptives. Patient has no known allergies, but further clarification on her reaction to her contraceptive is needed.
Psychiatric rationale: Full evaluation needed; need clarification of what OCD sx/tendencies she displays and need to rule out any other psychiatric issues.
Diagnostic Tests: ROS, patient complaint, and patient history help rule out several of the differentials. Nonetheless, any patient complaining of chest pains should have BP/checked and be given an ECG regardless of the situation. Depending on those results further cardiac workup may or may not be needed. In this case it would also be important to check thyroid functioning and do a 12 panel drug screen via urine analysis just to be sure given there are potential psychiatric concerns. A psychiatric evaluation would also be pertinent here.
Differential Diagnosis:
Diagnosis
Pertinent Positives
Pertinent Negatives
MI
Chest Pain/shortness of breath
No tingling, numbness, left arm pain. Pain subsides with controlled breathing. Patient is young, physically active, denies substance usage, and in good shape.
AF
Chest Pain/Periods of rapid heart rate
Heart rate increases are situation specific (anxiety provoking situations). Decrease in sx with breathing exercise.
Atrial flutter
Periods of rapid heart rate
Heart rate increases situation specific (anxiety provoking situations). Decrease in sx with breathing exercise.
MVP
Anxiety, panic, some psychiatric sx.
Again it appears these sx are situation specific — sx declines with controlled breathing
ARDS
Heart racing — shortness of breath
Absence of trauma or recent surgery.
PE
Sudden onset of chest pain, shortness of breath
Patient is very active running several miles weekly. Sx with controlled breathing.
Hyperthyroidism
Heart racing, feeling nervous suddenly
Situation specificity of sx
Diabetes
Anxiety attack
No other sx consistent with this dx. Situation specific sx.
Seizure disorder
Anxiety sx.
No other reported sx that would suggest seizures such as blackouts, staring episodes, lost periods of time.
Intoxication, withdrawal, untoward medication effects
Lo/Ovral and oral contraceptives are known to precipitate panic attacks.
Denies drug, ETOH use. No formal evidence of intoxication from patient description.
Psychiatric disorder
OCD sx identified.
No formal psychiatric dx made at this time. Reality testing appears intact on examination. Patient does not appear manic or depressed.
Diagnosis: Panic attack. So far patient does not meet diagnostic criteria for panic disorder (requires recurrent panic attacks and we are not yet sure if the panic attack is related to her use of oral contraceptives, based on patient history it does not appear to be due to cardiac or pulmonary factors). Moreover, there is not enough information on the patient’s psychological issues to determine if this attack is related to another psychiatric condition.
Pathophysiology: For panic disorder the pathophysiology is unknown at this time. Suspected involvement of epinephrine triggering the fight-or-flight response in specific fear provoking situations leading to sympathetic nervous system arousal, vasoconstriction, dizziness and lightheadedness.
A genetic hypothesis of panic disorder has attempted to define specific genetic loci associated with the disorder, but it has been without success.
From a neuroanatomy standpoint it is believed that perhaps panic attacks are mediated by a fear network involving the amygdala, the hypothalamus, and brainstem. However this model is speculative at best.
Cognitive theories propose that people with panic disorder have a keen sensitivity to internal autonomic cues, but again this is speculative.
Evaluation, Education, and Health Promotion:
Until there is more information regarding this patient’s psychiatric status the patient should be given a means to induce relaxation and breathing techniques to reduce any future reoccurrences. Patient should be referred to her psychologist as well as a psychiatrist for further evaluation and education.
References:
Afifi, T.O., Asmundson, G.J.G., Taylor, S., & Jang, K.L. (2010). The role of genes and environment on trauma exposure and posttraumatic stress disorder symptoms: a review of twin studies. Clinical Psychology Review, 30, 101-112.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington, DC: Author.
Andersson, G. (2011). Panic disorder. In W.T. O’Donohue & C. Draper (Eds.) Stepped Care and e-Health (pp. 61-76). New York: Springer.
Barlow, DH (Ed.). (2008). Clinical handbook of psychological disorders (4th ed.). New York: Guilford Press.
Cloos, J.M. (2005). The treatment of panic disorder. Current Opinions in Psychiatry, 18(1), 45-50.
Dains, J., Bauman, L., & Scheibel, P. (2012). Advance health assessment and clinical diagnosis in primary care (4th ed.). St. Louis, MO: Elsevier Moby.
Eaton, W.W., Dryman, A., & Weissman, M.M. (1991). Panic and phobia. In L.N. Robins & D.A. Regier (Eds.), Psychiatric disorders in America (pp. 155 — 179). New York: Free Press.
Fleet, R., Lesperance, F., Arsenault, A., Gregoire, J., Lavoie K., & Laurin C. (2005). Myocardial perfusion study of panic attacks in patients with coronary artery disease. American Journal of Cardiology, 96(8), 1064-1068.
Johnson, M.R., Lydiard, R.B., & Ballenger, J.C. (1995). Panic disorder: Pathophysiology and drug treatment. Drugs, 49(3), 328-344.
Katerndahl, D.A & Talamantes, M. (2000). A comparison of persons with early-versus late-onset panic attacks. Journal of Clinical Psychiatry, 61(6), 422-427.
Lang, P. & McTeague, L.M., 2009. The anxiety disorder spectrum: fear imagery, physiological reactivity, and differential diagnosis. Anxiety, Stress & Coping
22, 5-25.
Sadock, B.J. & Sadock, V.A., (2007). Kaplan and Sadock’s synopsis of psychiatry:
Behavioral sciences/clinicalpsychiatry (10th edition). Philadelphia: Lippincott Williams & Wilkins.
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