B.S. DOB: 12/25/1992

GENDER: Female

Race: Caucasian

RELIGION: Catholic

MARITAL STATUS: Single

OCCUPATION: College Student

CHIEF COMPLAINT: "I am scared. I feel like I can't catch my breath and my chest hurts."

Differential Diagnosis: There are a number of differential diagnoses for these presenting symptoms. The major ones will be explored here.

Possible Diagnosis

Myocardial infarction (MI), angina, acute coronary syndrome

Prodromal symptoms include fatigue, chest discomfort, or malaise in the days before the MI. A typical STEMI may occur without warning. Onset is not directly associated with severe exertion but concomitant with exertion. Other symptoms include: anxiety, light-headedness with or without syncope, nausea or indigestion, cough, diaphoresis, and/or wheezing.

Physical Exam: Physical symptoms can be variable. The typical chest pain of an acute MI is intense and continuous for 30-60 minutes, retrosternal, and may radiate up to the neck, shoulder, and jaw and down to the ulnar aspect of the left arm and may be described as burning, squeezing, aching, or sharp. Sometimes the main symptom is epigastric with indigestion. Hypertension or hypotension may be present depending on the foci of the MI. Acute valvular dysfunction may be present. Other symptoms such as confusion, anxiety, a sense of impending doom, profound restlessness, diaphoresis, weakness, presyncope, hiccupping (which reflects an irritation of the diaphragm or phrenic nerve), vomiting, and palpitations may be present. Atypical presentations may include abdominal discomfort, jaw pain, altered mental status (more often in elderly patients) or atypical chest pain. Nearly half of MIs are clinically silent as they are not associated with the symptoms described above and may go unrecognized.

Diagnostic Testing: Blood pressure monitoring, (ECG/EKG), cardiac imaging, cardiac catherization, coronary artery calcium scoring, cardiac biomarkers/enzymes, troponin levels, creatine kinase levels, myoglobin levels, check kidney functions and electrolyte levels, evaluate medications.

Atrial fibrillation (AF)

History: Clinical presentation can also be variable from asymptomatic atrial fibrillation with rapid ventricular response to cardiogenic shock or CVA. The majority of AF episodes are asymptomatic. Three patterns of AF: paroxysmal AF -- terminate spontaneously within seven days but the majority last less than 24 hours; persistent AF - last more than seven days and often require pharmacologic or electrical intervention; Permanent AF - persisted for greater than one year.

Physical Exam: An AF dx is based on the physical finding of an irregular heart rhythm.

Diagnostic Testing: A 12-lead ECG would be appropriate.

Atrial flutter

History: Palpitations, "fluttering" sensation in the chest, shortness of breath, anxiety, general weakness.

Physical Examination: Typically a macro reentrant arrhythmia with atrial rates of between 240 and 400 beats per minute.

Diagnostic Testing: ECG

Mitral Valve Prolapse (MVP)

History: Symptomatic MVP is divided into three categories: symptoms related to autonomic dysfunction, symptoms related to the progression of mitral regurgitation; and symptoms that occur as a consequence of some other complication such as a CVA or other complication. Symptoms related to autonomic dysfunction (usually congenital) include anxiety, panic attacks, fatigue, arrhythmia, atypical chest pain, orthostasis, syncope, and/or neuropsychiatric symptoms.

Physical Exam: MVP classic auscultatory finding is a mid-to-late systolic click and/or murmur.

Diagnostic Testing: Physical examination, echocardiography.

Acute respiratory distress syndrome (ARDS).

History: Characterized by the development of acute hypoxemia and dyspnea typically 12-48 hours following some event (although it may be even longer after the event). Events such as trauma, sepsis, drug overdose, massive transfusion, acute pancreatitis, or aspiration. The event may be obvious or it may be difficult to identify depending on the case.

Physical Exam: Often presents with nonspecific symptoms such tachypnea, tachycardia, and the need for a high fraction of inspired oxygen (FIO2) in order to maintain oxygen saturation. May be febrile or hypothermic.

Examination of the lungs may reveal bilateral rales. If ARDS occurs as a result of sepsis there may be hypotension and peripheral vasoconstriction with cold extremities and possibly cyanosis of the lips and nail beds. If sepsis is not readily apparent pay attention for signs of lung consolidation or findings consistent with an acute abdomen. Any recent wounds drain sites, and decubitus ulcers should be examined for infection. Check for subcutaneous air, a manifestation of infection or barotrauma.

Diagnostic Testing: ADRS is a clinical diagnosis so an acute onset of symptoms is noted, chest radiograph, hemodynamic monitoring, and/or bronchoscopy.

Pulmonary Embolism (PE)

History: Classic presentation is sudden onset of pleuritic chest pains, shortness of breath, and hypoxia. However, many do not display these symptoms at often people who died from PE complained of nagging symptoms for weeks before their death.

Physical Exam: Nonspecific clinical signs and symptoms. Sometimes dyspnea, tachypnea, or chest pain.

Diagnostic Testing: Can be lengthy. Typically pulse oximeter with mild exertion (walking) will identify suspect cases.

Hyperthyroidism

History: Anxiety, increased perspiration,...

Medication side effects.
History: Repeated use or intermittent use of drugs or alcohol to cope or escape from stress.

Physical Exam: Slurring words, balance difficulties, hyper or hypoactivity, over or underarousal, drowsiness, autonomic signs, nausea.

Diagnostic Testing: Urinalysis, chemistry panel analysis. Cardiac markers, measurement of prothrombin time, or toxicology screening may be indicated.

Psychiatric disorders

History: The history will depend on the specific disorder in question. Panic attacks are associated with a number of psychiatric disorders including panic disorder, obsessive compulsive disorder, schizophrenia, bipolar disorder, major depressive disorder, posttraumatic stress disorder, phobic disorders, and somatization disorder.

Physical Exam: Interview with the patient. Look for signs of psychosis (loose associations, delusions or hallucinations), mania (pressured speech, hyperactivity), depression (decreased affect, amotivation, slowed responses).

Diagnostic Testing: Structured Clinical Interview for DSM-IV Axis I disorders (SCID-I).

History of Present Illness:

B.S. is a 19-year-old Caucasian female who presents to the university health center with CC "I am scared. I feel like I can't catch my breath and I have chest pain." States that she started to feel nervous about 10-15 minutes ago. Her pulse then started racing and she experienced moderate chest pain ( 6/10 on pain scale). She then started to feel short of breath. She stated she" felt like she couldn't get air in or out, she started having chest pain and her heart felt as though it was going to jump out of her chest." She stated she felt as though she was" going to lose control." Prior to" feeling a little nervous "she was sitting in the library studying for her chemical engineering final that is due to take place tomorrow morning. She stated she has never had any breathing difficulties or chest pain in the past. She stated that "her heart does race right before she starts her exams" but it has "not stopped her from taking exams and usually resolves after she answers a few questions. She admits to "feeling a sense of doom."

While sitting in the waiting room she was advised by another student to breathe in through her nose and out through her mouth slowly. She reports that after doing so for approximately two minutes she had some relieve of her symptoms and was able to breathe normally. She still feels a little faint and scared. She stated that she still has mild chest pain (3/10). Denies tingling or numbness of the hands and fingers, denies visual disturbances, denies diaphoresis, denies trembling, denies nausea, vomiting or abdominal pain, denies pain radiating to jaw/down left arm. Denies smoking/drug use/no caffeine use. No history of hypertension, MI, hyperlipidemia, asthma, bronchitis, pneumonia, pulmonary emboli, obesity, poor physical conditioning, pneumothorax, foreign body aspiration, phobias. Denies experiencing symptoms like this before. Admits to having obsessive compulsive tendencies.

Past Medical History:

Allergies: NKDA

Medications (prescription): LoOvral I po qd

Medications (OTC): Tylenol ES ii tablets po q 4-6h prn headache. Systane lubricant eye drops I or ii drops OU prn dryness.

Vitamins/Herbs/Supplements: One a Day multivitamin capsule a day

Last Exams: PCP- Family MD 6/7/12 for routine GYN check up and birth control pills, normal exam, LMP current. Optometrist: 5/25/2012 normal exam with no need for glasses. Dentist: about 6 months ago for routine cleaning with no cavities, due to see dentist next month for routine care. Psychologist-PhD as needed to follow up on control of obsessive compulsive tendencies. Dermatologist-MD every 6 months for mole check. Last visit about 3 months ago and normal.

Childhood: Denies measles, rubella, mumps, whooping cough, chickenpox, rheumatic fever, scarlet fever. Hospitalizations for acute bronchitis @ 5 yo and appendectomy @ 14 yo.

Surgical: Appendectomy (2005) with no complications, 3 impacted wisdom teeth extracted (2006) with no complications. Lasik surgery OU (2007) with no complications except for onset of dry eye syndrome.

Psychiatric: Admits to obsessive compulsive tendencies but not diagnosed with obsessive compulsive disorder (OCD).

Vaccinations: Tetanus (2006), declines both flu and pneumovax. Has had all childhood required and…