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CPC Case for November 18, 2004

Discussant: Dr. John Tan, MD
Presenter: Dr. Kristina Hursey, MD

CC

Chest pain

HPI

38 year old African-American female presented with a 1 day history of chest pain. The pain began while she was cleaning her house and was not relieved by rest.  The severity of the pain had increased from 5/10 at onset to 10/10 at presentation. She described it as constant, “sharp” pain that was substernal and worse with   coughing or deep breathes. She reported severe nausea and several episodes of vomiting. She denied diaphoresis, dyspnea, or palpitations.
PMH
  1. Ulcerative colitis s/p total colectomy (1995) and ileoanal J-pouch anastomosis (2002)
  2. Abdominal aortic aneurysm-In July 2002, she had a AAA repair with graft placement. She had reimplantation of celiac axis, superior   mesenteric artery, and renal arteries which was complicated by acute renal   failure.  In June 2003, she had another AAA repair proximal to the   previous AAA repair.
  3. End stage renal disease-hemodialysis via right arm arteriovenous fistula   dependent since first AAA repair in July 2002.  She is currently on the renal transplant list.
  4. She denied any history of hypertension or diabetes mellitus
MEDICATIONS
  1. Calcium acetate (Phos-Lo)  2 tabs po TID
  2. Epoetin alpha (Procrit)  5000 units SQ 3 times/wk
  3. Sodium bicarbonate  2 tabs po BID
  4. Loperamide (Imodium) prn for diarrhea
FH Father 59  (alive)  Colon cancer
  Mother  58 (alive)   HTN, DM
  Two siblings, ages 33 and 34, who are healthy

SH

She is single and lives with her 15 year old son.  She previously worked as a hair stylist, but has been on disability since 11/2002.  She rarely drinks alcohol.  She denied tobacco or illicit drug use.  She is heterosexual, and had not been sexually   active.  She had received blood transfusions.
ALLERGIES Penicillin  (rash)
ROS

She reported some mid-back pain and occasional diarrhea.
She denied fever, chills, headache, visual changes, cough, abdominal pain, or lower extremity edema.
PHYSICAL EXAM: Vitals:
T98.1  P79  R18  BP168/104
Gen: Obese, black female sitting upright in bed in moderate distress due to chest pain
HEENT: Anicteric sclerae, mucous membranes pink and moist. Neck: Supple, Carotids 2+ bilaterally without bruits, no JVD or thyromegaly.
Lungs: Normal work of breathing, Clear to auscultation bilaterally.
Heart: Regular rate and rhythm.  Normal S1 and S2.  No murmurs, rubs, or gallops.
Abd: Midline vertical scar.  Soft, non-tender, non-distended, normal active   bowel sounds.  No hepatosplenomegaly.
Ext: No lower extremity edema.  2+ dorsal pedis and radial   pulses.  Right arm AVF.
   

LABS:

Na
  140
K
  3.8
Cl
  93
HCO3
   26
Glucose
   110
BUN
 26
Ca
  9.6
Mg
  2.3
Phos
  4.2
 
     
Creatinine
 6.5
Alk Phos
   207
AST
  13
ALT
  12
TP
  8.4
Alb
   4.0
Total Bili
0.4
Lipase
   137
Lactic Acid
  
  Glob
  4.4
 
       
           
 
       
Trop I
   5.0
CK
   734
CKMB
   5.30
  CRP
  26.5
  BNP
 311  
WBC
 12.1
Hgb
 12.6
Hct
 43
Plts
 367
Differential
 nl
MCV
 94
ABG:
ESR
 56
:
Imaging and Other Studies
EKG
 sinus rhythm at 83 bpm, left axis deviation, and left anterior fascicular block.
Portable chest x-ray:
 cardiac silhouette normal, left lower lobe atelectasis.
A diagnostic procedure was performed.