Aquifer Case Study AP Discussion

Discuss the history of present illness that you would take on this patient in preparation for the clinic visit. Include questions regarding Onset, Location, Duration, Characteristics, Aggravating Factors, Relieving Factors, Treatment, Severity (OLD CARTS).

Describe the physical exam and diagnostic tools to be used for Ms. Johnston. Are there any additional you would have liked to be included that were not?

What plan of care will Ms. Johnston be given at this visit; what is the patient’s education and follow-up?


Before seeing the patient, Dr. Lorenzen asks you to review the differential diagnosis for chest pain. She reminds you, “There are many causes of chest pain including cardiac, gastrointestinal, pulmonary, musculoskeletal and psychogenic causes.”

Question List below three potential causes of chest pain in each of the categories mentioned. 7/13/19, 3(41 PMInternal Medicine 02: 60-year-old woman with chest pain 

The suggested answer is shown below.

  • Pericarditis, Myocardial Infarction, Aortic Dissection, GERD, Esophageal Spasm, Heart
  • Burn, Pneumonia, Pleuritis, Flu, Costochondritis, Trauma, Lower Rib Pain Syndrome, Anxiety, Hyperventilation, Depression.

Letter Count: 207/1000


Answer Comment See Teaching Point below

  • Broad DiFFerential Diagnosis of Chest Pain
  • Cardiovascular Causes of Chest Pain
  • Symptoms Signs Other abnormalities


  • Chest pressure that may radiate to neck/arm/shoulder. May have associated
  • May have abnormal blood pressure, lower
  • May have ST segment


Artery DiseaseArtery Disease

  • dyspnea. Risk factors include obesity, diabetes, hypertension and hyperlipidemia. extremity edema, cardiac murmurs or normal exam. abnormalities on EKG.

Variant AnginaVariant Angina

  • Vasospastic cause of angina, often younger pt with few risk factors. Risk factors include tobacco use.
  • Between episodes of chest pain, physical exams may be completely normal.
  • Accompanied by transient ST elevation on EKG.

Cocaine Induced Chest Pain

  • Chest pain after cocaine use from infarction or intense coronary spasm.
  • Patients may have burn marks on lips and fingers from crack pipe, needle marks on skin from injections, and/or inflammation and ulcerations in the pharynx and nasal septa.
  • Urine tox screen positive for cocaine and drug metabolites. Elevated CPK levels may be seen with associated rhabdomyolysis.

Aortic Dissection

  • Crushing or tearing quality pain in the center of the chest, radiates to the back.
  • Murmur of aortic insufficiency may be present.
  • Widened mediastinum on CXR.

Valvular Heart DiseaseDisease

  • Aortic stenosis can result in anginal pain. Mitral prolapse patients often have atypical chest pain.
  • AS – systolic crescendo decrescendo murmur, MVP – midsystolic click with possible late systolic murmur.


  • Severe retrosternal, often pleuritic, pain that varies with body positioning. Pericardial friction rub.
  • Diffuse ST elevation and PR depressions on EKG, pericardial effusion on echocardiogram.
  • Non-ischemicNon-ischemic CardiomyopathyCardiomyopathy
  • Usually does not manifest as chest pain but rather dyspnea or other CHF symptoms.
  • Pulmonary edema, hepatic congestion, lower ext edema, jugular venous distension.
  • Enlarged heart on CXR, elevated b- type natriuretic peptide.

Cardiac Syndrome X

  • Exertional angina- like chest pain, more common in women.
  • Usually normal EKG, abnormal exercise stress test with normal coronaries on angiogram and no evidence of coronary spasm.

Similar to:

  • Myocarditis pericarditis but can also mimic ischemia.
  • May manifest as CHF.
  • Cardiac enzymes may be elevated.


  • Gastrointestinal Causes of Chest Pain

Symptoms Signs Other Abnormalities

Esophageal DiseaseDisease

  • Reflux associated chest pain usually occurs after meals, is exacerbated by lying down or bending over, and improved by antacids. May be associated with chronic cough.
  • May be associated with laryngitis or posterior oropharyngeal erythema in severe cases.


  • Usually presents with right upper quadrant or epigastric pain. Pain may be Murphy’s sign – tender palpable gallbladder with a sudden halt of Abnormal liver function exacerbated by fatty foods and may be accompanied by nausea and/or vomiting. inspiration with palpation in the upper quadrant. Occasional jaundice tests

Peptic Ulcer Disease

  • Gnawing, midepigastric pain.
  • Epigastric tenderness
  • Ulceration/inflammation seen on endoscopy


  • Moderate to severe mid epigastric pain with radiation to the back. May be accompanied by nausea and vomiting. Epigastric tenderness
  • Elevated amylase and lipase