Case of the Month

Things to consider:
  • When did the problem start?
  • How has it progressed? (Describe chronologic sequence).
  • Where is the problem?
  • Describe your problem being as specific as possible.
  • What other symptoms, if any, have you noted over the same time?
  • Who around you has had similar problems?
  • What have you tried for the problem and how well did it help?
  • How has the illness impacted your daily life?

 
 

Things to consider BEFORE you see your doctor:

Joseph's information:
 

Your Past Medical History

 

  
  • High blood pressure for 2 years
  • Diabetes mellitus for 14 years
  • High cholesterol
  • Prior gallbladder surgery
  • Eye surgery due to diabetes complications

Your Current Medi-cations [

  
  • HCTZ 25 mg once daily for blood pressure
  • Insulin 70/30. 12 units each morning and  6 units each evening for diabetes
  • Lovastatin 40mg each evening with dinner for high cholesterol
  • Aspirin 81 mg daily
  • Tylenol as needed for occasional aches and pains

Your Social History

  • Has smoked 2 packs per day for 43 years (2 X 43 = 86 pack years)
  • Drinks 2-3 beers each night
  • Works on computers

Your Family History
  • Father had heart attack at age 49
  • Mother alive and doing well with no major illnesses
  • Younger sister has diabetes. Two older sisters are alive and have no major illnesses
  • Three brothers
  • Has 3 sons, one of which has diabetes
Your Medi-cation allergies: none
Your Surgical History: none
   
 Name: Joseph

Age: 49

Chief complaint (reason for seeing his physician):  Chest pain

 "Doctor, for the past 8 days I have experienced something I have never experienced before and it scares me. I have noticed progressive chest pain just behind my breast bone. On the first day it lasted almost 3 minutes, but each day it seems to get a little more intense and lasts 20 or 30 seconds longer.  It feels like someone is tightening a rope around my chest.  It only hurts when I am active and never occurs at rest. The pain does not move any place and I don't hurt any place else. When the chest pain comes on it seems to build up until I get someplace and sit down. After I relax, it takes less than 30 seconds to go away. I tried antacids, thinking it was just my usual heartburn, but this did not help at all. 

I have  noticed  my heart thumping pretty hard when the chest pain occurs, so much so that it makes me dizzy.  Also, when I experience the chest pain, I feel short of breath.  This is really frightening for me because I have never had any problems breathing in the past.  Other than the symptoms I just mentioned, I've been feeling great.

Prior to last week, I was doing just great and had no aches or pains at all. I have worked full-time as a floor manager for the past 17 years and most of the day I have to walk around, but since this started, I can't seem to walk more than 30 or 40 feet before my chest starts hurting, so I have had to take off work this week.

My dad died of some heart problem in his late 40s and my mom said his older brother died of a heart attack in his mid 50s, so naturally, I am pretty nervous about all this.
 

Doctor's commentary - This is a good  explanation of his illness.  In less than 1 minute, Joseph gives a great deal of pertinent and specific information that will help me diagnose him quickly and effectively, without the need for a lot of unnecessary testing.
Doctor's decision making process:

Joseph is 49 years old, and while his age alone does not put him at high risk for heart disease, he has a very important family history.  His father had a heart attack at a relatively early age, which increases Joseph's risk for the same. In addition, Joseph has high blood pressure, long-standing diabetes, and high cholesterol, all risk factors for coronary artery disease (heart disease).  His 86 pack year smoking history dramatically increases his risk for heart disease. 

Tests ordered in the doctor's office: He has an EKG, which was completely normal.

Disposition: Emergency room.  Joseph needs to be transported to the nearest emergency room for further evaluation for heart disease, possibly unstable angina (which means he is at immediate risk for a heart attack).  Despite a normal EKG, his story is very concerning for heart disease and I will not want to waste time and money on additional  tests and procedures.  He needs urgent evaluation.