Medical Diagnosis help identify patient problems and helps to come up with medical solutions. Ihuman case studies are based on real-life like patients that are diagnosed and subjected to tests and medical evaluations. It is important to have an essential understanding of these studies as they help to prepare for real life medical situations.
Here is a Case Study of Cindy Wagoner
Patient: Cindy Wagoner 57 y/o
CC: Chest pain
HPI: Ms. Wagoner a 57 year old female 10 days status post inferolateral STEMI with stent placement, presents to the ED with a 2 hour history of progressively worsening chest pain. The pain is sharp/stabbing, worse with deep inspiration and movement, and sometimes shootinginto her back with respiration, it is relieved somewhat by sitting up and leaning forward. She reports mild nausea, without vomiting, denies fever/chills, palpitations, lightheadedness/syncope, SOB, cough, URI, or extremity/catheterization site pain or swelling. She reports compliance with her antiplatelet medications since discharge. On exam she is febrile and has a pericardial friction rub. She is not hypotensive or hypoxic. PMH is significant for hypertension, hyperlipidemia, tobacco use, and obesity.
Medical Evaluation
PMHX:10 days status post mi, s/p rca catheterization with stent placement; unsuccessful lca ballon angioplasty
Rx: Clopidogrel 75 mg daily, atorvastatin 80 mg daily at bedtime, lisinopril 2.5 mg daily, Carvedilol 3.125 mg daily at bedtime, pantoprazole 40 mg daily, and aspirin 81 mg daily.
Allergies: Bactrim
Preventative health:
Immunizations: Doesn’t know if immunizations are up to date
FHx: Father had a heart attack when he was 59. Both his mother and sister have type-2 diabetes. She doesn’t have kids. She is not aware of her grandparent’s health.
SHx: Smokes a pack and a half for 25 years but is quitting now that she’s had a heart attack. Started a health heart diet after her first heart attack.
ROS:
General- Tired with chest pain
Skin/hair/nails- Negative
HEENT- Negative
Breast- Negative
Cardiovascular- Chest pain
Respiratory- Negative
Gastrointestinal- Mild nausea
Genitourinary- Negative
MSK- Negative
Hematologic- Negative
Endocrine- Negative
Neurological- Negative
Psychological- Nervous
Physical Examination
On exam she is febrile and has a pericardial friction rub. Differentials:
- Myocardial infarction- because of the chest pain, nausea, and past medical history
- Aortic dissection- because of acute chest pain
- Myocarditis- because of fever and recent MI
- GERD- because of chest pain
- Pulmonary Embolism- because of chest pain, dyspnea, hypoxia, sinus tachycardia
- Pericarditis- associated with chest pain, tachycardia, fever, friction rub, muffled heart sounds, and recent MI
- Pneumoniae is associated with acute dyspnea, hypoxia, rigors, crackles
- Pneumothorax- because of acute dyspnea, hypoxia, pleuritic chest pain, decreased breath sounds.
- Cardiac Tamponade- because of chest pain. Excluded because of elevated jvd, hypotension, muffled heart sounds not present.
Tests:
cTnT- Normal
ECG- Normal sinus rate, diffuse pr depression, st elevation v2-v6.
TTE- mild pericardial effusion without impaired contractility decreases suspicion for a tamponade CBC- Mild leukocytosis
CKMB- Normal
ESR- abnormal and elevated GERD cocktail- Negative
Chest x-ray PA and lateral- Normal
Assessment & Plan: Pericarditis
- Admit for close cardiac monitoring, given her multiple high risk features
- Acetaminophen for fever management and reduction of metabolic demands
- Supplement oxygen above 94%
- Aspirin
- Cardiology consult for anticoagulation
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