อาการวิทยา
(SYMPTOMATOLOGY)
Case Study: Part 2
Introduction to Clinical Medicine
วิชาบทนําเวชศาสตร์คลินิก (RAID 303) นักศึกษาแพทย์ชั้นปีที่ 3
คณะแพทยศาสตร์โรงพยาบาลรามาธิบดี มหาวิทยาลัยมหิดล
สารบัญ
หน้า Chest pain case 1 Part 2.................................................................................4 Part 3.................................................................................6 Chest pain case 2 Part 2.................................................................................8 Part 3.................................................................................10 Syncope case 1 Part 2.................................................................................11 Part 3.................................................................................13 Syncope case 2......................................................................14
PART 2 Case Study
Chest pain case 1 : Mrs. Naree
The patient is a 73-year-old housewife who presents to the emergency room with sudden episode of severe midsternal, sharp, tearing chest pain. Additional history and information are obtained from patient’s husband and medical record. Past Medical • History of orthopnea and paroxysmal History nocturnal dyspnea (PND) for the past two months • Controlled hypertension. • No prior history of coronary artery disease • Medications: antihypertensive medication. • Allergies/intolerances : none Family Unknown History Social / • The patient lives with her husband. Occupational • Nonsmoking, no alcohol abuse, History no substance abuse. Physical Temperature : 37oC, respiration: 24/min. examinations Blood pressure : Left arm : 130/45 mmHg; right arm: 160/50 mmHg Pulse : 100/min; regular, weak left radial pulse, absent right femoral pulse. Weak bilateral carotid pulses, especially on the right
4 | Symptomatology part 2
PART 2 General The patient is in moderate distress. Not pale, no Appearance jaundice, no cyanosis Head and Neck • Weak, bilateral carotid pulses, especially on the right. • No bruits. • Neck vein is not distented. Jugular venous pressure (JVP) is 3 cm above the sternal angle. Chest and lungs • No dullness to percussion • Normal breath sound on auscultation. Cardiac exam • Normal to palpation. • Normal S1, faint S2, grade 2/6 early diastolic blowing murmur heard at 2nd, right intercostal space. • S3 and S4 gallops detected at the apex • No pericardial rub Abdomen No mass, no organ enlargement. Extremities Cool and pale, no cyanosis, weak left radial pulse, absent right femoral pulse. Neurological No gross neurological deficit Exam
Question 1. List pertinent history and physical findings of this patient.
2. What do you think is the cause of her chest pain?
Symptomatology part 2 | 5
PART 3 Case Study
Chest pain case 1 : Mrs. Naree
Discussion and summary: Pertinent lab tests: WBC 13,500/ď L, Hgb 11.8 g/dl, glucose 113 mg/dl, creatinine 1.3 mg/dl. Electrocardiogram showed sinus bradycardia, voltage criteria for left ventricular hypertrophy, and no sign of ischemia. Chest roentgenogram revealed a normal cardiac silhouette, normal lung fields, and a slightly widened mediastinum at the level of the arch of the aorta. After stabilization, The patient underwent emergent chest and abdominal CT with intravenous contrast, revealing an extensive aortic dissection involving the ascending, arch, descending thoracic, and abdominal portions of the aorta. The intimal flap was seen extending into the right brachiocephalic trunk, as well as into both common iliac arteries. No extramural hematoma was identified. Emergent portable transthoracic echocardiography confirmed the presence of a very proximal intimal flap at the level of the sinotubular junction, severe aortic regurgitation, and a small pericardial effusion. The appropriate therapy in this patient is immediate surgical repair with an artificial graft. This case illustrates the devastating impact of proximal aortic dissection, and its potentially misleading presentation. The classic presentation of acute aortic dissection is characteristically sudden “rippingâ€? chest pain in 80-90% of patients, with a diastolic murmur heard in 40-50% of proximal dissections. Various other symptoms and signs depend on the compromise of blood flow in specific branches of the aorta by the intramural hematoma or intimal flap.
6 | Symptomatology part 3
PART 3 A recent registry of 513 patients with proximal (type A) dissections reports that neurological deficits in general occur in 18% of patients, mostly manifesting as syncope. Pulse deficits were seen in the right brachiocephalic trunk in 14.5% of patients, and in the left carotid artery in 6.0%. Carotid pulse deficits were strongly related to death: 14.6% of the patients who died had References Bossone E, Rampoldi V, Nienaber CA, et al. Usefulness of pulse deficit to predict in-hospital complications and mortality in patients with acute type A aortic dissection. Am J Cardiol 2002;89:851-5
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PART 2 Case Study
Chest pain case 2 : Mr. Somsak
The patient is a 60-year-old business man who presents to the emergency room with severe midsternal chest pain for one hour. He feels tightness in his chest and the pain radiates to jaw and left arm. He has tried antacid with no improvement. He has never experienced such a severe persistent pain before. For the past 2 years, he has been treated for his high blood pressure. He had occasional chest pain when he exerted too much, like walking a few flights of stairs, but the pain went away after taking a rest. He takes medication regularly: propranolol, clopidogrel and statin. Family Unremarkable History Social / He actively runs his own construction business Occupational and smokes one package of cigarette per day but History no alcohol nor substance abuse. Physical Temperature : 37oC, respiration: 20/min. examinations Blood pressure : 160/90 mmHg on both arms Pulse : 52/min; regular and full. The carotid pulses are normal.
General The patient is in mild distress. Not pale, Appearance no jaundice, no cyanosis
8 | Symptomatology part 2
PART 2 Head and Neck • No bruits. • No neck vein distention. Jugular venous pressure (JVP) is normal. Chest and lungs • No dullness to percussion • The breath sounds are normal Cardiac exam • Normal to palpation. • Normal S1 and S2, • S3 and S4 gallops detected at the apex • No pericardial rub, no murmur Abdomen No mass, no organ enlargement. Extremities No edema Neurological No gross neurological deficit Exam
Question
1. What are the active problems of this patient?
2. What is the most likely cause of his chest pain?
Symptomatology part 2 | 9
PART 3 Case Study
Chest pain case 2 : Mr. Somsak
Discussion and summary: Pertinent lab tests: WBC 13,500/ď L, Hgb 11.8 g/dl, glucose 113 mg/dl, creatinine 1.3 mg/dl. Troponin is increased Electrocardiogram showed sinus bradycardia, voltage criteria for left ventricular hypertrophy with strain and myocardial ischemia is suggested Chest roentgenogram reveals a normal cardiac silhouette, normal lung fields, After stabilization, The patient underwent emergent cardiac catherization and revealing an extensive narrowing involving the left anterior descending (LAD) and right coronary artery (RCA). Percutaneous transluminal coronary angioplasty (PTCA) was performed on both LAD and RCA successfully. Patient was subsequently transferred to CCU and discharged home 3 day after admission
10 | Symptomatology part 3
PART 2
Syncope
case 1 : Mr. Boonsom
The patient is a 70-year-old retired government officer who presents to the emergency room after a black-out. He is alert when he arrives and gives a history that he was jogging in the park when he suddenly felt dizzy and fainted. His wife was with him and noticed that he dropped on the ground and lay still with no shaking of his arms or feet, no urination or defecation. He came to within 5 minutes and was transferred to this hospital by ambulance. In the past he occasionally had chest pain and shortness of breath on exertion. This was once told by a doctor that he has abnormal heart sound. Family Unremarkable History Social / The patient lives with his wife. Occupational Nonsmoking, no alcohol abuse, History no substance abuse. Physical Temperature : 37oC, respiration: 24/min. examinations Blood pressure : 160/90 mmHg on both arms and legs in supine and sitting position
Pulse : 572/min; regular Slow upstroke of bilateral carotid pulses with thrill
General Alert and oriented, not pale, no jaundice, no Appearance cyanosis
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PART 2 Head and Neck • No bruits. • Neck vein distention. Jugular venous pressure (JVP) is 8 cm above the sternal angle. Chest and lungs • No dullness to percussion • Bilateral basal fine crepitation heard on auscultation. Cardiac exam • The PMI is at 5th ICS, just lateral to midclavicular line with heaving on palpation. • Normal S1, faint S2, grade 2/6 midsystolic crescendo/decrescendo ejection murmur at the base, and a grade 2/6 early diastolic blowing murmur. • S3 and S4 gallops detected at the apex • No pericardial rub Abdomen No mass, no organ enlargement. Extremities No edema Neurological The patient is not in acute distress, exam he is alert and oriented.
Question
1. What are the active problems of this patient?
2. What is the most likely cause of his syncope?
12 | Symptomatology part 2
PART 3
Syncope
case 1 : Mr. Boonsom
Discussion and summary: pertinent lab tests: WBC 13,500/ď L, Hgb 11.8 g/dl, glucose 113 mg/dl, creatinine 1.3 mg/dl.The electrocardiogram showed sinus bradycardia, left ventricular hypertrophy with strain, myocardial ischemia cannot be ruled out. Chest roentgenogram revealed a normal cardiac silhouette, normal lung fields. The echocardiogram showed moderate left ventricular hypertrophy with normal ejection fraction. Calcified and severe aortic stenosis and moderate aortic regurgitation were observed
Symptomatology part 3 |13
PART 2 Case Study
Syncope case 2 : Mr. Sakda
The patient is a 62-year-old retired teacher who presents with repeated episodes of fainting. He has had 4-5 such episodes in the past 2 months. Each episode comes on quite suddenly without any premonitory symptoms, he faints and then “comes to� in about a minute or so. Others have observed some of these spells and tell him that he lies motionless and quickly wakes up with no after-effects. The episodes come at no particular time of day and do not seem to be related to any special event like eating, exercising, walking, urinating, coughing, suddenly standing up, turning his head to the side.So far as he can recall, each episode occurred while he was sitting or standing, though he thinks one happens in bed. Other than mild diabetes which is well controlled by diet, he has been in good health. He has no chest pain, dyspnea, or orthopnea, but he occasionally feels a palpitation in his chest. His memory is good. The system review is negative. Family No family history of sudden death. History Social / Married with 2 sons, no smoking, no alcohol Occupational abuse, no substance abuse. History
14 | Symptomatology part 2
PART 2 Physical Temperature : 37oC, respiration: 24/min. examinations Blood pressure : 160/90 mmHg on both arms and legs in supine position, and 150/85 mmHg in sitting position
Pulse : 52/min; regular with frequent extra beat
General Alert and oriented, not pale, no jaundice, no Appearance cyanosis Head and Neck • No bruits. • Neck vein is not distended Chest and lungs • No dullness to percussion • The lungs are clear on auscultation. Cardiac exam • Apex beat at 5th ICS, just lateral to MCL • Normal S1, and S2 • No S3 nor S4 gallops detected • No pericardial rub Abdomen No mass, no organ enlargement. Extremities No edema Neurological No detectable neurological deficits exam
Question
1. What is the main problem of this patient?
2. What is the diagnosis or differential diagnosis of his fainting attack?
Symptomatology part 2 |15