NP Virtual Rounds February 9, 2010

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

2. Case Review • 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