Question

Discussion Board – Review Chapter 14 Clinical Encounter vignettes and share your thoughts on your chosen vignette and add support to your views using sources referenced in APA Clinical-Encounter Vignette Part I: Making a Diagnosis for a Patient Presenting with Chest Pain Bob Brown is a 50-year-old insurance salesman who comes to the doc- tor complaining of chest pain that usually occurs in the middle of the night, lasts for about an hour, and goes away. These symptoms have been present for eight to ten months and are gradually worsening. Mr. Brown reports general good health and takes no medicine; he almost never goes to the doctor. He quit smoking ten years ago. His father had a heart attack at age 65. His physical exam is normal, except that he is 30 pounds overweight and his blood pressure is mildly elevated. His total serum cholesterol level is moderately high. His resting electrocardiogram is normal. Dr. Lore and Dr. Skeptic go through the same steps in pursuing a diagnosis as they: 1. make a mental list of plausible diagnoses based on their education and experience, 2. think about the consequences of missing any diagnosis or of pursuing treatment for the wrong diagnosis, and 3. decide which tests will aid them in making the correct diagnosis. On the basis of experience, they both rank three plausible diag- noses for his chest pain: (1) gastroesophageal reflux disease (GERD, or heartburn), (2) coronary heart disease (angina), and (3) chest wall pain. They agree that the pain is not typical for coronary disease, and the normal physical exam argues against chest wall pain. Dr. Lore recalls his cardiology teachers’ admonitions—never miss a case of coronary disease because you may next see the patient in the morgue—and he remembers certain past patients with this atypical sort of chest pain who ended up having coronary disease more vividly than he remembers those who had something less serious. Dr. Lore tells Mr. Brown that he should have a heart catheterization procedure (dye injected through a long tube threaded into the heart) as soon as possible, and immediately refers him for this test. He tells the patient that if the catheterization is normal, he should have some tests done on his throat (esophagus) and stomach to determine if he has GERD. Mr. Brown’s heart catheterization is normal. Dr. Lore refers Mr. Brown for a fiber-optic exam of his stomach and esophagus (endos- copy), plus 24-hour monitoring for acid in the esophagus. GERD is the diagnosis. Also noting that Mr. Brown’s blood pressure is still high, Dr. Lore adds the diagnosis of hypertension. Dr. Skeptic has a different approach as he thinks about the evi- dence base that can help him rank the probabilities of the three hypothesized diagnoses, help gauge the short- and long-term risks of misdiagnosis, and help him weigh the accuracy of diagnostic tests against their risks and costs. His experience and the results of obser- vational studies on the incidence, prevalence, and natural history of the diagnoses in question tell him that: 1. In this type of practice setting, about 15 percent of patients who gave a history of chest pain unrelated to exercise had coronary disease, 19 percent had GERD, and 36 percent had chest wall pain (Klinkman, Stevens, and Gorenflow 1994). 2. About 4 percent of men this age in the general population have heart-related chest pain (angina), and about 3 percent report new- onset angina each year (Rosamond et al. 2007). 3. According to his heart disease risk factors, this patient has about a 1.4 percent per year risk (which means a 13.2 percent risk over the next ten years) of having a heart attack (MI), and there are effective treatments to prevent MI (Grundy et al. 2004; Wilson et al. 1998). 4. According to studies of men referred for exercise treadmill testing, Mr. Brown’s chance of having coronary disease of sufficient severity to require bypass surgery or other invasive treatment is 10 to 15 percent (Pryor et al. 1991). 5. GERD is common and uncomfortable but not very dangerous; it can rarely lead to esophageal cancer after being present with uncontrolled symptoms for many years (exact risk unknown). Treatment often requires long-term use of prescription medicines to control symptoms, but treatment may not reduce the risk of cancer (Moayyedi and Talley 2006). 6. Chest wall pain with no obvious etiology based on history and physical exam poses no significant health risk, and it usually resolves on its own, but it can be treated with a short course of an over-the-counter analgesic such as aspirin. Dr. Skeptic also concludes that coronary heart disease would be the most important diagnosis not to miss. However, the evidence sug- gests that Mr. Brown has less than a 15 percent chance of having coro- nary disease and that the risk of a fatal or nonfatal MI occurring within the next few weeks is very low. Given that the pain is unlikely to be from his chest wall (according to his physical exam), it is more likely that Mr. Brown has symptomatic GERD, which is treatable but usually not dangerous. Therefore, Dr. Skeptic feels that there is time to care- fully consider the next diagnostic steps. Studies on the risks and accuracy of potentially useful tests reveal that: 1. In this type of practice setting, about 15 percent of patients who gave a history of chest pain unrelated to exercise had coronary disease, 19 percent had GERD, and 36 percent had chest wall pain (Klinkman, Stevens, and Gorenflow 1994). 2. About 4 percent of men this age in the general population have heart-related chest pain (angina), and about 3 percent report new- onset angina each year (Rosamond et al. 2007). 3. According to his heart disease risk factors, this patient has about a 1.4 percent per year risk (which means a 13.2 percent risk over the next ten years) of having a heart attack (MI), and there are effective treatments to prevent MI (Grundy et al. 2004; Wilson et al. 1998). 4. According to studies of men referred for exercise treadmill testing, Mr. Brown’s chance of having coronary disease of sufficient severity to require bypass surgery or other invasive treatment is 10 to 15 percent (Pryor et al. 1991). 5. GERD is common and uncomfortable but not very dangerous; it can rarely lead to esophageal cancer after being present with uncontrolled symptoms for many years (exact risk unknown). Treatment often requires long-term use of prescription medicines to control symptoms, but treatment may not reduce the risk of cancer (Moayyedi and Talley 2006). 6. Chest wall pain with no obvious etiology based on history and physical exam poses no significant health risk, and it usually resolves on its own, but it can be treated with a short course of an over-the-counter analgesic such as aspirin. Dr. Skeptic also concludes that coronary heart disease would be the most important diagnosis not to miss. However, the evidence sug- gests that Mr. Brown has less than a 15 percent chance of having coro- nary disease and that the risk of a fatal or nonfatal MI occurring within the next few weeks is very low. Given that the pain is unlikely to be from his chest wall (according to his physical exam), it is more likely that Mr. Brown has symptomatic GERD, which is treatable but usually not dangerous. Therefore, Dr. Skeptic feels that there is time to care- fully consider the next diagnostic steps.

Answer 1

CORONARY HEART DISEASE: causes impaired blood flow in the arteries that supply blood to the heart. SYMPTOMS: The symptoms includes: a) pain in the chest b) indigestion c) lightheadedness d) sweating e) nausea f) fast heart rate and g) shortness of breath.

GERD (GASTROESOPHAGEAL REFLUX DISEASE ) : is a disease in which stomach acid or bile irritates the food pipe lining.

SYMPTOMS: The symptoms include: a) acid regurgitation b) difficulty in swallowing c) chronic sore throat d) bad breath e) inflammation of the gums f) laryngitis g) sudden excess of saliva production and h) cavities.

CHEST WALL PAIN: indicates pain and tenderness in the costochondral junction ( which is the area along the sides of the breastbone where the ribs attach).

SYMPTOMS: The symptoms include: a) aching b) stabbing c) sharp pain d)pain worse when move your chest or arms e) pain increases when you breathe deeply, sneeze or cough.

In this case, physicians has conducted routine blood test for heart attack and performed Cardiac Catheterization. This shows an elevated cholestrol level, which may be the cause of hypertension but cardiac catheterization shows normal findings meaning, chest pain is not the cause in this case. Moreover, the symptoms of heart attack are onset and that doesnot continue for months. So, the other diagnosis GERD can be suggested because often people mistake this heartburn in GERD as symptoms of heart attack.

GERD and CHEST PAIN: In this diseases, the chest pain occurs because stomach acid is splashing into the esophagus, which is a classic reflux symptom. The pain due to heartburn lasts longer and be more intense than expected.