1. Define all unknown terms:

Angina:

Radiation:  Pain secondary to Myocardial ischenia or injury can radiate along medial aspect of left arm, to jaw , shoulders and epigastrium. Pain of Ureteral stones can radiate down to genitals.  Pain of dissecting aneurysm radiates to back.

Apical Heart rate: Pulse rate and apical rate should be the same when the heart is regular. If it is irregular the heart rate can be higher than pulse rate.

S2: Second heart sound

S4: Fourth heart sound. Heard when the compliance of the myocardium is stiff. (Hypertension, Aortic stenosis)

R2ICS: Second right intercostal space. 

Apex: The lower and outermost detectable cardiac impulse.

Indirect Inguinal Hernia: The hernial sac is a patent processes vaginalis and the neck of the sac is situated at the deep inguinal ring, lateral to the inferior epigastric artery.

Direct Inguinal Hernia: protrudes directly through the posterior wall of the inguinal canal, medial to the inferior epigastric artery.

 

 

 

 

 

 

 

 

2. Cite the primary clinical problem (not the diagnosis)

Chest discomfort or pain

 

 

 

 

 

 

 

 

 

 

 

3 .Develop a general differential diagnosis of this clinical problem using categories of disease. Cite examples from each:

The objective is intended to help you understand that a given clinical problem or complaint may have many different causes. You should be aware that chest pain may arise from different organs or anatomical locations.

CT chest showing structures in Thorax

Cardiovascular: Angina
Acute myocardial infraction
Pericarditis
Aortic dissection
Gastrointestinal: Reflux esophagitis
Esophageal spasm
Esophageal rupture
Pulmonary: Pneumothroax
Pleuritis/pneumonia
Pulmonary embolus/infarction
Musculoskeletal: Traumatic injury
Costochondritis
Herpes zoster
Somatization: Anxiety

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. In general, what factors (data) would you take into consideration when determining a differential diagnosis of specific diagnosis:

 

 

 

 

 

 

 

 

 

 

 

5. Develop a specific differential diagnosis (higher probability causes of chest pain in this patient).

To answer  this question you need to know the characteristic pains of different probabilities

Angina:

Acute myocardial infarction: 

Reflux esophagitis: 

Somatization:  One of the most common office complaints is a primary care setting is chest "pain" or discomfort. The complaint often reflects somatization. A point should be made that not all pain is organic; therefore, the physician should pursue psychosocial stresses which may be the initiator of this problem. 

Pericarditis. Precardiac, sharp, persistent.  Worse in recumbent position Relieved by sitting.

Dissecting aorta. Sharp stabbing pain radiating to back. Asymmetry of pulses.

Chest wall Lesions

Musculo-skeletal injury:  

Pneumothorax: Pain is sudden in onset, localized, sharp, worse on deep breathing and coughing. Associated with shortness of breath.

Pleuritis/pneumonia  Pain is sudden in onset, localized, sharp, worse on deep breathing and coughing. Associated with productive cough, fever and  chills. 

 

 

 

 

 

 

 

6. What is your diagnosis: Why?

Our primary working diagnosis should be Angina:

We will keep in mind the possibility for Reflux esophagitis and Somatization:( His business is poor and his son is always getting into trouble. Reasons for him having anxiety.) Esophagitis can simulate cardiac pain closely and often can co-exist.

 

 

 

 

 

 

 

 

7.Describe the Coronary arterial system.

Coronary artery  Dissection of the heart  (Dr John McNulty)

Coronary artery  Dissection of the heart  (Dr John McNulty)

Coronary Artery:   Branches  (Drawing)

 

 

 

 

 

 

 

 

8. How is blood flow (oxygen supply) to myocardium  regulated and accomplished?

Muscular artery  Another medium-sized, muscular artery.  (Dr John Clancy)

Small blood vessels   Small blood vessels, with 3-layered walls. (Dr John Clancy)

Heart wall   The heart wall, like blood vessels in general, has three main layers. (Dr John Clancy)

Blood flow to Heart  Low power of a Mallory-stained heart, showing two channels that are continuous with the lumen of the left ventricle. (Dr John Clancy)

 

 

 

 

 

 

 

 

 

 

9. What is the patho-physiology of Myocardial ischemia?

Myocardial O2 demand exceeds the ability of the coronary arteries to supply oxygenated blood.

"The presence of atherosclerosis is not the same as the risk the disease presents. More people die
with atherosclerosis than die of it! "

Coronary thrombus:  Thrombus coronary artery  Gross picture (Dr. Ralph Leischner)

Coronary thrombus:   Histo  (Dr. Ralph Leischner)

 

 

 

 

 

 

 

 

 

 

 

 

 

10.What are the risk factors for this disease in this patient?

Mr. Solomon has most of these risk factors

 

 

 

 

11. What is the significance of determining levels of low density (LDL) and high density (HDL)  lipoproteins in a patient with increased cholesterol ?

HDL: 

LDL: 

 

 

 

 

 

 

 

 

Sensitivity is the proportion of patients with disease that have a positive test. 

Specificity is the proportion of patients without the disease that have a negative test.

 Positive predictive value is the frequency with which a positive test actually means that the patient has the condition.

Negative predictive value is the frequency with which a negative test actually means that the patient does not have the condition.

The likelihood ratio for a positive test is a ratio of the proportion of patients with the disease who have a positive test (the true positives) to those without the disease who have a positive test (the false positives).

The likelihood ratio for a negative test is the ratio of those with the disease who have a negative test (the false negatives) to those without the disease who have a negative test (the true negatives).

 

 

 

 

 

13. In considering Mr. Solomon’s presentation with "pain on my chest" what are the key parts of the history and physical that influence how you develop a differential diagnosis? Qualitatively, what is your impression of the sensitivity and specificity of the historical and physical exam findings?

Mr. Solomon presents with a history of chest pain that is related to exertion and gets better with rest. Chest pain or discomfort is a relatively sensitive question for coronary artery disease but not specific. Mr. Solomon also has a burning chest discomfort that occurs late at night, after large meals, when lying down. More specific details for angina as the diagnosis include the description of the pain as heaviness, the relation to exertion, the relief with rest. The details of the burning discomfort suggest gastro esophageal reflux disease (GERD)

Thus, the specificity of the diagnoses of angina and GERD are increased by the specific historical questions. The physical exam does not add much to either diagnostic possibility. In other words, the increased blood pressure is not particularly sensitive nor specific for the diagnosis of angina. The presence of hypertension, however, increases one’s concern that a patient may have angina given that hypertension is a known risk factor for coronary artery disease .

 

 

 

 

 

 

14 What are the options available for us to make a diagnosis of Angina.

 

 

 

 

 

 

 

 

15. What supplemental testing, if any, would you want in addition to the history, physical, and laboratory studies that are listed?

We need to consider Exercise test and Coronary angiogram

It would be reasonable to obtain an exercise test and, depending on the result of that test, proceed with a cardiac catheterization. 

One could easily argue, however, given the multiple risk factors and the high prior probability of coronary artery disease, that a negative exercise test may well be considered a false negative and one would go ahead with a Coronary Angiogram anyway. If that is one’ reasoning, then the exercise test would be a waste of time and money.

 

 

 

 

 

 

 

16. The characteristics of a patient determine how one interprets data obtained from that person. For example, a positive HIV test on a cloistered nun who has never had any sexual contact, blood exposure or other risk is almost certainly a false positive. In Mr. Solomon’s case, what characteristics, or risk factors, make you think it is likely that he has the diagnosis you consider most likely.  Given these characteristics, is there any point in supplemental diagnostic testing for Mr. Solomon? Would you believe a negative or positive test? Should be proceed directly to the "gold standard"?

 Mr. Solomon is a male smoker with hypertension, hypercholestrolemia, obesity, and a family history of coronary artery disease. The historical data and the risk factors make the prior probability so high that Mr. Solomon has angina, going directly to cardiac catheterization may well be the most reasonable course if one’s goal is to prove that the chest discomfort is angina and related to coronary artery disease. 

If Mr. Solomon is averse to invasive testing, a treadmill test might be useful to get a sense of the severity of the coronary artery disease. (i.e. if he drops his pressure with exercise then one would be concerned about left main obstruction and argue more forcefully about the need for a catheterization) and as therapeutic maneuver (e.g., if Mr. Solomon does not have EKG changes until he reaches a high double product, one could consider beginning a gentle exercise program as part of his therapeutic regimen.)

 

 

 

 

 

 

 

 

 

17. What drug therapy would you consider prescribing to control his symptoms?

Strategy  (Revisit Pathophysiology to plan a therapeutic option)

Widen this frame for better visualization

Decrease Myocardial Oxygen demand/Coronary artery vasodilatation:  

Protection against Myocardial Ischemia

Beta-blockers and or calcium channel blockers.
If organic nitrate therapy alone was inadequate to control Mr. Solomon’s angina, then the combination of an organic nitrate and beta-blocker or an organic nitrate with a calcium channel antagonist (verapamil, diltiazem, long acting dihydrophyridine derivative) would provide greater protection against ischemia. Triple therapy consisting of an organic nitrate, beta-blocker and calcium channel blocker might also be considered. The short acting dihydropyridine derivatives (nifedipine) have been shown to increase mortality in patients with coronary artery disease and should not be prescribed.

 

 

 

 

 

 

 

 

18. What  would you consider  to modify Mr. Solomon’s risk factors ?

Alter risk factors

 

19. What drug therapy would you consider  to prevent further progression of obstruction to Coronary arteries ?

Prevent Coronary thrombosis: Aspirin
Since aspirin reduces the risk of heart attack (coronary thrombosis) in patients with coronary artery disease there is a strong indication for daily aspirin (160 mg/day) therapy. Aspirin causes irreversible inhibition of platelet cyclooxygenase, decreased thromboxane A2 production and decreased platelet aggregation. Then aspirin is given as prophylactic therapy to reduce the risk of intracoronary thrombosis and would probably have little effect on Mr. Solomon’s angina.

 

 

 

 

 

 

 

20. What options do we have to relieve mechanical obstruction of Coronary arteries ?

Angioplasty:

Coronary Artery Bypass Surgery