1. NP Virtual Rounds February 9, 2010 Atypical chest pain Case Review

2. 64 y/o aboriginal woman w/ initial reports of L chest wall pain beginning of 2009 to present PMH: obstructive hydrocephalus treated w/ residual intermittent headaches, diplopia, nausea &balance issues, L cerebral aneurysm clipped, cataracts Bronchietasis w/ partial lobectomy age 33, osteoporosis, smoker, depression/anxiety, H. pylori last treated Mar 09, Fe deficiency anemia,TB as child Medications: long hx T3s, valium – recent switch to codeine/clonazepam, pariet, ferrous gluconate, puffers, didrocal Allergies: NKA Social hx: retired RN, lives on reserve

3. Case continued HPI: Jan 09 - L chest wall pain coinciding w/ h/ pylori, chest infection and wrist/back/shoulder joint issues, not coming back for regular appts for f/u Plan – treat infections stomach/lungs, CXR N, discussed smoking cessation, trial of oxycocet for pain w/ physio I see her in June – L chest wall & rib pain, nausea & dizzy, some cough & sputum, no cp/sob, smoking ½ pk/day, no etoh/caffeine decreased, unsteady on feet P/E – chest – crackles mid-lower bases bilateral, L UQ pain but palpable mass RUQ distal to liver, no rebound/guarding, urine dip + blood only, neuro grossly normal aside from balance Diff dx – r/o pneumonia, abd mass NYD, r/o UTI, vertigo Plan: Biaxin 500 mg bid; repeat CXR, blood work – cbc, lfts, renal/liver fx, TSH, U/A; rush abd U/S, consider CT head follow Monday

4. Case continues Pt did not attend f/u appts– blood work reviewed anemia, falling eGFR, low Na/Cl, - issues vertigo, abd mass, query pneumonia Not seen until July by locum LUQ/chest wall pain persists, trouble breathing & sob, CXR N, Abd U/S N, Diff dx – costo-chrondritis, query COPD – treated w/ naproxen, diazepan, spirva Seen by me few days later – naproxen helping L chest wall pain, arthritis in wrists/shoulders worse, not taking spirva but willing to try atrovent to help w/ breathing – chest better since I saw her last Diff dx – L chest wall pain, COPD, - booked PFTs, arthritis ?RA, falling eGFR, anemia Plan – nephrology, rheumatology, add ES tylenol for pain control Seen by physician partner Sept - persistent L chest wall pain, hip pain – x-rays + double doctoring

5. Case to present Pt seen by me again in Nov Review of all dx tests – anemia, dropping Hgb, low Na CXR, hip & lumbar spine osteoporosis, h/ pylori Feb w/ otherwise normal gastroscopy/colonoscopy; also reviewed meds – not taking pariet, Fe, or didrocal L breast pain – had for several months, persistent, post menopausal, no masses – needs mammo – last 2004 w/ had lump T3 use – likely exceeding max dose of acetaminophen w/ ES L chest wall pain Urinary frequency/dribbling Diff dx- thinking changing ? Compression fracture/cardiac/RA Plan – asked locum dr to see – cardiac work up w/ internal medicine & return to ortho, ordered labs, echo & asked to come back for CPX

6. Case to present continued H. pylori back – tx’d, x-ray thoracic spine query compression # Cardiac work up negative Normal mammogram Plan for ortho to deal w/ deformity & pain w/ surgical option Changed T3s to codeine Working on anemia

7. Discussion Atypical chest pain in older women Co-morbidities Effective f/u Multiple issues at each visit Prescribing of narcotics/context of what is happening in my practice Different approaches of practitioners Other cases recently