NP Virtual RoundsFebruary 9, 2010

Atypical chest pain

Case Review

Case Review64 y/o aboriginal woman w/ initial reports of L chest wall pain beginning of 2009 to present

PMH:

obstructive hydrocephalus treated w/ residual intermittent headaches, diplopia, nausea &balance issues, L cerebral aneurysm clipped, cataracts

Bronchietasis w/ partial lobectomy age 33, osteoporosis, smoker, depression/anxiety, H. pylori last treated Mar 09, Fe deficiency anemia,TB as child

Medications: long hx T3s, valium – recent switch to codeine/clonazepam, pariet, ferrous gluconate, puffers, didrocal

Allergies: NKA

Social hx: retired RN, lives on reserve

Case continuedHPI: Jan 09 - L chest wall pain coinciding w/ h/ pylori, chest infection and wrist/back/shoulder joint issues, not coming back for regular appts for f/u

Plan – treat infections stomach/lungs, CXR N, discussed smoking cessation, trial of oxycocet for pain w/ physio

I see her in June – L chest wall & rib pain, nausea & dizzy, some cough & sputum, no cp/sob, smoking ½ pk/day, no etoh/caffeine decreased, unsteady on feet

P/E – chest – crackles mid-lower bases bilateral, L UQ pain but palpable mass RUQ distal to liver, no rebound/guarding, urine dip + blood only, neuro grossly normal aside from balance

Diff dx – r/o pneumonia, abd mass NYD, r/o UTI, vertigo

Plan: Biaxin 500 mg bid; repeat CXR, blood work – cbc, lfts, renal/liver fx, TSH, U/A; rush abd U/S, consider CT head follow Monday

Case continuesPt did not attend f/u appts– blood work reviewed anemia, falling eGFR, low Na/Cl, - issues vertigo, abd mass, query pneumonia

Not seen until July by locum LUQ/chest wall pain persists, trouble breathing & sob, CXR N, Abd U/S N, Diff dx – costo-chrondritis, query COPD – treated w/ naproxen, diazepan, spirva

Seen by me few days later – naproxen helping L chest wall pain, arthritis in wrists/shoulders worse, not taking spirva but willing to try atrovent to help w/ breathing – chest better since I saw her last

Diff dx – L chest wall pain, COPD, - booked PFTs, arthritis ?RA, falling eGFR, anemia

Plan – nephrology, rheumatology, add ES tylenol for pain control

Seen by physician partner Sept - persistent L chest wall pain, hip pain – x-rays + double doctoring

Case to presentPt seen by me again in Nov

Review of all dx tests – anemia, dropping Hgb, low Na CXR, hip & lumbar spine osteoporosis, h/ pylori Feb w/ otherwise normal gastroscopy/colonoscopy; also reviewed meds – not taking pariet, Fe, or didrocal

L breast pain – had for several months, persistent, post menopausal, no masses – needs mammo – last 2004 w/ had lump

T3 use – likely exceeding max dose of acetaminophen w/ ES

L chest wall pain

Urinary frequency/dribbling

Diff dx- thinking changing ? Compression fracture/cardiac/RA

Plan – asked locum dr to see – cardiac work up w/ internal medicine & return to ortho, ordered labs, echo & asked to come back for CPX

Case to present continued

H. pylori back – tx’d, x-ray thoracic spine query compression #Cardiac work up negativeNormal mammogramPlan for ortho to deal w/ deformity & pain w/ surgical optionChanged T3s to codeineWorking on anemia

Discussion

Atypical chest pain in older womenCo-morbiditiesEffective f/u Multiple issues at each visitPrescribing of narcotics/context of what is happening in my practice

Different approaches of practitionersOther cases recently