Case Answers:
Case answers will be presented after review of the HPI.
Answer 1
What is needed, first of all, is a full, meticulous, complete medical history. We
have very little information about the pain. This needs to be characterized in much
greater detail. There seems to be more than one pain here, so each one needs to be
characterized. So far, it is not suspicious for aortic disection, pleuritic or an acute
cardiac disorder.
Answer 2
Refer to handout - Table 242-1 - and also Appendix A in the case on CAD.
Answer 3
Chronic, episodic.
Answer 4
Substernal, diffuse, characterized by a burning, heaviness, squeezing, not
necessarily a "pain", precipitated by exertion or strong emotion, promptly
relieved by rest or NTG.
Answer 5
Induced by movement, lasts for hours/days or fleeting (seconds), pinpoint
localization.
Answer 6
Aortic stenosis, IHSS (hypertrophic cardiomyopathies), severe pulmonary
hypertension.
Answer 7
Esophageal disease, chest wall syndrome, hyperventilation/panic disorder.
Answer 8
There definitely seems to be more than one pain. The one described as exertional
discomfort seems to be typical angina. It is chronic. But one also gets the feeling that
there has been an increase in the frequency (unstable?). There is another epigastric, long
lasting pain associated with nausea and vomiting, which is rather rare in comparison to
the other, and the sharply localized anterior pain associated with movements.
Answer 9
CASS: 62% of patients with typical history had CAD (strongly suggestive)
40% with "probable ischemic"
4% with nonischemic (very low risk)
The term "nondiagnostic" (indeterminate) should be used when the history doesn’t allow clear differentiation.
Answer 10
Some of her frequent episodic chest pains are exactly reproduced by mechanical
manipulation of the thorax. This and the compatible history make chest wall pain likely as
an explanation for this pain. However, there is more than one kind of pain and combined
disorders is likely.
She is postmenopausal, not on hormonal replacement therapy. Her blood pressure is mildly elevated. She has hypertensive vascular changes in the fundi. The femoral bruits are suggestive for peripheral vascular disease of atherosclerosis. The xanthelasma and arcus senilis are suggestive for hyperlipidemia. The younger you are the more reliable is the arcus.
Answer 11
S4 is a diastolic sound heard following atrial contraction into a non-compliant
ventricle. It usually is seen in hypertrophy of the LV or ischemia.
Answer 12
The history is indicative that she is at high risk: she is postmenopausal, obese,
sedentary, with a positive family history of premature CAD, is mildly hypertensive and has
evidence on exam of peripheral vascular disease.
A lipid profile (HDL, LDL) and FBS are needed for a complete assessment.
At her age, with these risk factors and with typical anginal symptoms, she has an 80-85% probability of having significant CAD.
Answer 13
The following are ordered and found to be normal except as noted:
EKG: Usually normal in patients with CP, including angina. It helps: to recognize prior MI; to recognize other cardiac problems, i.e., LVH, IHSS, pulmonary HTN, arrhythmias; to serve as a baseline for the EST, i.e., to determine if abnormalities exist that will make the EST difficult to interpret.
CXR: Rarely helpful in patients without pleuritic pain; in general not helpful in evaluating patients with CP. Here, the patient does have chest wall pain and bony and intrathoracic abnormalities should be sought.
Echocardiogram: Performed to evaluate the murmur, and to determine left ventricular function.
As has been stressed repeatedly, the most useful "test" is the H&P. Other tests, like those listed above, are commonly performed but much abused since they are all too often ordered for the wrong reasons, done routinely, or are misinterpreted because of failure to correlate the test result with the patient’s clinical situation. Thyroid function tests could also be ordered but there is nothing clinical to suggest thyroid dysfunction
.
Answer 14
Her discomfort (‘indigestion") is clearly exertional, brief in duration
and relieved by rest. In a patient of this age, with her risk factors, such a history is
virtually diagnostic.
Answer 15
Her angina occurs only with rather vigorous physical exertion and does not
compromise her usual daily activities (NYHA Class II).
Answer 16
This is not a test done for diagnosing angina but rather to assess her anginal risk
profile.
In general, EST is indicated in the following circumstances:
* High risk: angina is severe and/or unstable, objective exercise tolerance is poor, and/or those whose left ventricular function is impaired.
Answer 17
80-85% in a patient with typical symptoms.
Answer 18
60%
Answer 19
Acute myocardial infarction. The most useful clinical indicators (besides a typical
history) is a prior history of CAD and the EKG.
Answer 20
Only 1% of patients (>30yo) with completely normal cardiograms were found to
have an acute MI (4% had unstable angina).
Answer 21
75% of patients with acute MI have new findings of ischemia, strain or infarction.
By the same token, reliance on the EKG alone misses about 15% of MI’s.
Answer 22
ST segment elevation and Q waves in > 2 leads, not known to be old.
Answer 23
EKG: Is almost always abnormal in patients with an acute MI.
A normal study excludes nothing.
CXR: A normal study usually excludes aortic dissection, pneumothorax, pneumonia,
pneumomediastinum and esophageal rupture.
Answer 24
To rule out a myocardial infarction, unstable angina, "ominous" stress
test results, post-MI angina, post-CABG angina.
Answer 25
Pneumonia, viral or idiopathic pleuritis, pulmonary embolism, chest wall disorders,
bronchial asthma, and pericarditis.
Answer 26
Pneumonia, pulmonary embolism.