Chest Pain History-Case 1
Chest Pain History-Case 1
Please assess the student as they take the following history
Student's Email

CASE - The evaluating student should read the following case and role-play for their peer

Dear Student: The following exercise is meant to be done as a role-play.  One student should read the case and role-play the patient.  The other student should act as the physician, and should not read the case or the checklist in advance. A third student, or the "patient", should complete the checklist during the interview to track their peer's progress.

 

Case:  Ms. CA

 

     You are Mrs. CA, 57 year-old woman who works as an administrator in a large law firm in downtown Toronto.  You live with your husband of 25 years and have 3 adult children that live on their own.  You are going to the doctor today because you have been experiencing episodes of chest pain that have been increasing in frequency and severity.

 

     Your chest pain started about one month ago.  The episodes last between 10-30 minutes, though in the past week they have been getting longer and longer.  Initially, they only occurred once or twice per week- normally after dinner- but recently they have been occurring almost every day.  Your episodes of chest pain tend to occur about 1 hour after meals, though they have also occurred at night (the pain was severe enough to wake you from your sleep).  You also frequently wakes up with a sour taste in your mouth.  You are able to make the pain subside a little bit by walking around or taking a Tylenol.

 

     Your chest pain feels like a burning pain in the middle of your chest.  The pain is a 7/10 when it is at its worst.

 

     You are generally in good health.  You exercise regularly and do not notice that your chest pain is made worse with exercise.  You have no diagnosed medical conditions and take no medications.  You do not smoke, drink, alcohol, or use recreational drugs.  You have no allergies.  You have never experienced anything like this before and you are very concerned.  Though the episodes don't prevent you from participating in normal activities, you fear it may be something with your heart.  You have never had any medical conditions related to your heart but your brother had a heart attack when he was 52.

  

 Gastroesophageal Reflux Disease (GERD): GERD is condition that is defined by the presence of symptoms or complications resulting from the regurgitation of stomach acid into the esophagus.  The symptoms and complications from acid reflux result from acid-associated damage and inflammation of esophageal mucosa.  It’s important to note that not all people with GERD will have symptoms of heartburn.  The most common presenting symptoms of GERD are: heartburn (pyrosis—retrosternal burning pain, often post-prandial) and regurgitation (often of acid and/or small amounts of undigested food). (see:https://www.cagacg.org/uploads/guidelines/GERD%20Consensus%20Update%202004.pdf

 

INTRODUCTION - The student should perform the following:

Washes hands
       
Introduces self
       

IDENTIFYING DATA - The student should inquire about the following:

Name of patient
       
Age of patient
       

CHIEF CONCERN - The student should inquire about the following:

Nature of concern

The most common sources of chest pain are: MSK-related (36%), GERD (13%), stable angina (11%), myocardial infarction (1.5%)

       
Duration of concern
       

HISTORY OF PRESENT ILLNESS - The student should inquire about the following:

 Chest Pain

Onset of chest pain
               
Alleviating factors of chest pain
               
Quality of chest pain
               
Severity of chest pain
               
Radiation of chest pain
               
Location of chest pain
               
Timing of chest pain
               
Course and progression of chest pain
               

 

General Questions

Associated symptoms
               
Previous similar episodes (includes: investigations related to these episodes)
               
Impact on quality of life and work performance
               
Family history of heart disease
               

PERTINENT POSITIVES AND NEGATIVES - The student should inquire about the following:

Constitutional Symptoms

(Differential diagnosis includes: cancer, infection, and other systemic diseases)

Weight change
       
Fever
       
Fatigue
       
Change in appetite
       

Respiratory Symptoms

(Differential diagnosis includes: pulmonary embolism, pneumonia, asthma, COPD)

Wheezing
       
Pleuritic chest pain

Pleuritic chest pain is caused by inflammation of the pleural layers lining the lungs.  It is often described as a sharp/stabbing pain that is made worse with heavy breathing or coughing. 

               
Cough (includes: productivity, quality/quantity of sputum, blood in sputum)

GERD can present with a chronic cough.

               
Dyspnea
       
Exposures (includes: work exposures, travel exposures, infectious contacts)
               

Cardiac Symptoms

(Differential diagnosis includes: myocardial infarction, congestive heart failure, other myocardial dysfunction)

It’s important to ask about cardiac risk factors when suspecting GERD as they often have similar presentations and share some common risk factors (obesity, age).  Not only are the heart and the esophagus geographically close together, but they actually share some common innervation.

Dyspnea at night (paroxysmal nocturnal dyspnea)

Paroxysmal Nocturnal Dyspnea (PND) can occur in those with poor left-heart function.  After lying down, fluid redistribution due to gravity demands more activity from the left and right sides of the heart. In those who cannot match left-heart function with right-heart function, pulmonary congestion occurs, leading to symptoms of PND.

       
Dyspnea when lying down (orthopnea)

Orthopnea can occur in those with poor left-heart function when, after lying down, fluid redistributes due to gravity and causes pulmonary congestion.  It should resolve shortly after assuming a more erect position.

       
Palpitations
       
Chest pain
       
History of syncope
       
Personal or family history of heart attack, diabetes, heart failure
               
ECG or stress test
       

Gastrointestinal Symptoms

(Differential diagnosis includes: GERD, esophagitis)

Regurgitation (includes: Does it taste acidic/sour)

GERD is caused by disrupted function of the lower esophageal sphincter, either due to improper, transient relaxations, low pressure, or anatomic disruptions (such as hiatal hernia).  In addition to reflux of acid, morsels of undigested food may be regurgitated. 

               
Appetite changes
       
Odynophagia (painful swallowing)
       
Dysphagia (difficulty swallowing)

Alarm features in the presence of GERD symptoms include: dysphagia, vomiting, signs of GI blood loss, anemia, involuntary weight loss, chest pain.  In patients with GERD, dysphagia should be investigated if it does not completely resolve with adequate PPI therapy for 2-4 weeks.

       
Abdominal pain
               
Nausea/Vomiting
               
Excessive gas (belching or flatulence)
               
Changes in stool (includes: constipation, diarrhea, rectal bleeding, melena)
               
Association of pain with eating
       
History of heartburn
       

Musculoskeletal Symptoms

(Differential diagnosis includes: trauma, rheumatic disease)

Muscle pain
       
Joint pain (includes: erythema, stiffness, swelling, tenderness)
               
History of recent trauma
       

Psychiatric Symptoms

(Differential diagnosis includes: anxiety)

Nervousness/anxiety
       
Recent major changes in life/major stressors
       
Personal or family history of depression or other mental illness
               

MEDICATIONS AND ALLERGIES- The student should inquire about the following:

Medications (includes: prescription, over-the-counter, and herbal/alternative medicines)
               
Allergies to drugs or otherwise (includes: nature of reaction, timing of reaction, formal testing performed)
               

PAST MEDICAL HISTORY - The student should inquire about the following:

It is important to ask about diagnosed medical illnesses, surgeries, hospitalizations, and immunization history.  However, all relevant aspects of Past Medical History have been covered in the pertinent positives/negatives section (i.e. personal history of hypertension, hyperlipidemia, diabetes).

SOCIAL HISTORY AND HABITS - The student should inquire about the following

Smoking (includes: pack years; if they quit, when)
               
Drugs (includes: types, frequency of use, quantity, methods)
               
Alcohol (includes: quantity)
               
Living arrangement
               
Relationships & Children
               
Hobbies & Interests
               
Occupation
               

REVIEW OF SYSTEMS - The student should inquire about the following

Though it is important to perform a thorough review of systems when seeing patients, this is not relevant for this case.