Chief Complaint
“I can’t get rid of this acid reflux.” Patient reports acid reflux that has been worsening over the course of two weeks.
History of Present Illness
Mr. S is a 63-year-old otherwise well gentleman presenting to urgent care complaining of persistent acid reflex for two weeks that is unrelieved by his usual OTC medications including Prilosec, TUMS, Mylanta, and home remedies: baking soda, gingerale, and apple cider vinegar. His symptoms began two weeks ago, while resting at home. Denies aggravating or alleviating factors. Pt reports a burning pain from his abdomen to the middle of his chest rating a 6/10 on a verbal pain scale. Denies dizziness, lightheadedness, numbness or tingling to all extremities. He denies any shortness of breath, palpitations, fever, chills, or initiating any new medications. No N/V/D. Patient reports that he has not seen a physician in over 15 years and that he has no medical problems except acid reflux.
Past Medical History
GERD (include ICD-10)
Past Surgical History
Denies.
Family History
Maternal: The patient’s mother is currently living in a nursing home at 79 years of age. Her history is remarkable for hypertension, high cholesterol, right hip replacement (2/2018), and Atrial Fibrillation. The mother was not present at the bedside. Information was obtained from the patient.
Paternal: The patient’s father is deceased. He died from complications of a Myocardial Infarction at the age of 59 years old. His other history was remarkable for hypertension, high cholesterol, CABG, and COPD.
Social History
Cultural and/or Religious:
Patient is a Caucasian, Catholic man who does not require specific cultural or religious requests or needs during this encounter.
Environmental Exposure & Occupation:
He denies any recent hazardous or occupational exposure that may be contributing factors to this health problem. He reports that he is currently employed as a postal worker.
Marital Status:
He is currently married and lives with his wife of 40 years.
Current Health Habits & Potential Risk Factors:
- Alcohol: Socially, “a few times a month”
- Caffeine: Reports 2-3 cups of coffee daily
- Illicit Drug Use: Denies
- Tobacco: Reports smoking 1-1.5 packs of cigarettes daily x25 years
Current Medications:
Patient denies taking any medications.
Allergies:
NKA to medication, food, and environment.
Review of Systems (ROS):
Constitutional: Denies changes in appetite, weight gain or loss, fatigue, malaise, lethargy, or fever.
Skin, Hair & Nails: Denies changes to skin integrity, hair, or nails.
HEENOT: Denies headache, dizziness, changes in balance, difficulty hearing, or changes in vision. Denies oral lesions or pain. He reports no difficulty swallowing. He reports “I do not think I snore at night, but my wife tells me I do.”
Respiratory: Denies shortness of breath at rest and on exertion, cough, wheezing, and coughing up blood.
Cardiovascular: Reports burning in chest that feels similar to past experiences of acid reflux. Denies pressure, tightness, palpitations, edema or history of any cardiovascular issues.
Vascular: Denies any recent swelling to all extremities, bruising easily, or increase in bleeding.
Gastrointestinal: Reports heart burn. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in stool, and changes in bowel habits including incontinence.
Genitourinary: Denies dysuria, hematuria, incontinence, or changes in bladder habits.
Endocrine: Denies any intolerance or sensitivity to heat or cold. Denies any recent episodes of hypo or hyperglycemia.
Musculoskeletal: Denies any recent joint pain, swelling, erythema, stiffness, or weakness in all joints.
Neuropsychiatric: Denies any episodes of syncope, seizures, hallucinations, memory loss, changes in memory, or weakness. Denies unilateral weakness, speech impairment, numbness, tingling, or paresthesia. Denies anger issues, mood swings, and anxiety.
Objective:
Vital Signs: BP 124/90, HR 78, Oxygen Saturation: 97%, RR: 18, BMI: 30.5
EKG: 2mm ST elevation in anterior and inferior leads
Physical Exam:
Constitutional: In no acute distress. BMI in obese range.
Skin, Hair & Nails: Skin is warm, pink, and dry. Nails to bilateral hands and feet are pink. Angle between all nail plates and distal phalanx is 160 degrees. No clubbing or ridges present in nailbeds.
HEENOT: Head erect, midline, and symmetrical. No adenopathy to bilateral occipital lymph nodes. No tenderness noted to bilateral tragus. Bilateral gray, translucent ear drums. Patient hears and responds to normal conversational voice despite environmental noise. PERRLA. No adenopathy noted to preauricular and postauricular lymph nodes. Negative strabismus and nystagmus. Neck moves freely without any presence of lymphadenopathy to bilateral tonsillar, submandibular, submental, posterior cervical, superficial cervical, deep cervical, supraclavicular, and infraclavicular lymph nodes. Nares patent. Negative drainage. No bilateral frontal or maxillary sinus tenderness. Buccal mucosa pink, dry without presence of lesions. Tongue and uvula midline. No erythema to posterior pharynx. Tonsils are not enlarged. No exudate. Gag reflex present. Trachea midline.
Respiratory: Normal respiratory effort. Clear breath sounds bilaterally. Able to speak in complete sentences. No use of accessory muscles. No adventitious breath sounds were noted in all lung fields.
Cardiovascular: S1, S2 auscultated. No murmurs. No lymphadenopathy.
Vascular: No swelling noted to all extremities. No varicose veins.
Gastrointestinal: Soft, non-tender, nor distended. (+) bowel sounds x4 quadrants. No masses noted on palpation. No lymphadenopathy. Negative Murphy’s Sign, Psoas Sign, Obturater Sign, and McBurney’s Point.
Genitourinary: No CVA tenderness bilaterally.
Musculoskeletal: (-) pain, swelling, or redness noted to all extremities. Midsternal chest pain is not reproducible on palpation. Full ROM to all extremities.
Neuropsychiatric: AAOx3. Cranial nerves intact. Normal tone. 5/5 strength in all extremities. No reflexes or coordination abnormalities. Steady gait. Pt is cooperative, but hesitant with answering exam questions. Short replies to assessment questions. Pt appears anxious to finish examination.
Assessmeent: Determine Working Diagnosis and Must Not Miss Diagnosis
Differential Diagnosis
Cholecystitis ICD 10: K81.0
Cholecystitis is inflammation of the gallbladder that occurs most often due to an obstruction in the cystic bile duct by gallstones that arise from the gallbladder (Bloom, 2017). Cholelithiasis (gallstones) are commonly composed of cholesterol. “Obesity increases the biliary secretion of cholesterol, as a result of an increase in the HMG CoA reductase activity” (Dubhashi & Trinath, 2013). Mr. S is an obese man who has not had an evaluation by a physician in 15 years. The likelihood of him having untreated elevated cholesterol are very high resulting in cholelithiasis. Acute cholecystitis is frequently represented by pain in the epigastric region that may radiate to the right shoulder, scapula, or right upper quadrant of the abdomen. Mr. S demonstrated abdominal pain radiating to the epigastric region, which can be indicative of a gallbladder problem.
Dissecting Aneurysm (Must not miss) ICD 10: I71.01
Patients with acute aortic dissection often mistake their symptoms for musculoskeletal conditions. Thoracic aortic dissection should be included in differential diagnosis of many individuals presenting with chest pain. “Anterior chest pain and chest pain that mimics acute myocardial infarction usually are associated with anterior arch or aortic root dissection” (Mancini, 2017) The dissection interrupts blood flow to the coronary arteries, which results in myocardial ischemia. Patients with right coronary artery ostial dissection can present with acute myocardial infarction, commonly an inferior MI. Mr. S’s EKG revealed 2mm elevation in the inferior lead. With a present undiagnosed medical history and age falling in between the peak range for this to occur (50-65 years of age), dissection is a life threating condition that needs to be ruled out.
GERD ICD 10: K21.9
Gastroesophageal Reflux Disease (GERD) puts an individual at risk for both esophageal complications and extra-esophageal complications. GERD and Coronary Artery Disease (CAD) frequently co-exist and predispose patients to experiencing an Acute Myocardial Infarction (AMI). “The distal esophagus and the heart have overlapping sensory pathways and share a common afferent vagal supply, suggesting the notion that location and radiation of perceived pain may be identical” (Carmen, 2015). The first time “linked angina” was discovered was in a study performed in 1962. Stimulation of esophageal acid significantly reduced coronary blood flow producing angina. The development of AMI after the onset of GERD may be a result of activated inflammatory mediators (INL-6, INL-8, Ilβ, IFN-y, TNF-α, reactive oxygen species). These mediators have been significantly elevated in patients with GERD. “It is conceivable that chronic inflammatory process, vagal reflex overstimulation and sharing of common risk factors may be responsible for the association between GERD and AMI” (Carmen, 2015). PPI therapy has demonstrated a decrease in developing an AMI suggesting that the prevention of esophageal mucosal plays a role in reducing future myocardial ischemia. Mr. S. doesn’t have difficulty swallowing or report any aggravating factors such as worse when laying down. Both of these may be present with GERD. His symptoms are also not relieved with his PPI which should occur GERD.
Musculoskeletal Pain ICD 10: M79.1
A common cause of non-cardiac chest pain is musculoskeletal, especially fibromyositis. “Non-cardiac chest pain secondary to musculoskeletal disorders can be located anywhere on the chest wall (multiple painful sites are common)” (Cleveland Clinic, 2018).
STEMI / Acute Myocardial Infarction Working Diagnosis ICD 10: l21.9
Mr. S is at a very high risk for experiencing a myocardial infarction. He is over the age of 45 years old, smokes cigarettes, obese, and has family history of heart attack. The patient was sent out by ambulance to Bayshore Hospital After reviewing the chart, it revealed that Mr. S was not completely forthcoming with his family history. He formed the Emergency Room physician that his mother is deceased. She died at 79 years of age from complications of a Myocardial Infarction. However, he informed myself and clinical instructor that she was alive and fair health. The risk factors, EKG changes, and new-found familial history have placed Myocardial Infarction has my priority diagnosis. Myocardial ischemia can result from “esophagocardiac reflex”, which is “myocardial ischemia associated with chemical esophageal stimulation” (Lei et al., 2017). A study evaluated 50 Coronary Artery Disease (CAD) patients that underwent continuous ECG and esophageal pH monitoring for 24 hours to assess for ST-segment depression episodes and total duration of ischemic episodes. There were 218 episodes of ST-segment depression, 45% (20.6%) correlate with pathologic reflux. (Lei et al., 2017). When comparing these patients to individuals who do not have GERD, patients with GERD had significantly higher number of ST-segment depression episodes and total duration of ischemic episodes (Lei et al., 2017). “It is critically important to recognize this association and initiate treatment with PPIs in appropriate patients with CAD and concomitant GERD as it might improve GERD and prevent future adverse cardiac events (Lie et al., 2017). This patient has been experiencing GERD for multiple years without taking any PPIs. The uncontrolled GERD predisposes him to cardiac complications in addition to the other multiple risk factors mentioned above.
References
Atamanalp, S., Keles, S., Acemoglu, H., & Laloglu, E. (2013). The Effects of Serum Cholesterol, LDL, and HDL Levels on Gallstone Cholesterol Concentration. Retrieved, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809189/
Bloom, A. (2017). Cholecystitis. Retrieved from https://emedicine.medscape.com/article/171886-overview
Carmen, H. (2015). Acute Coronary Syndrome: An Unusual Consequence of GERD. Retrieved from https://www.hindawi.com/journals/cric/2015/939641/
Cleveland Clinic. (2018). Non-Cardiac Chest Pain. Retrieved September 23, 2018, from http://www.clevelandclinic.org/health/health-info/docs/0200/0294.asp?index=4900
Colletti, P.M., Barakos, J.A., Siegel, M.E., Ralls, P.W., & Halls, J.M. (1987). Enterogastric Reflux in Suspected Acute Cholecystitis. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/3608334
Dubhashi, S., Trinath, T. (2013). Is Severity of Cholecystitis Related to Body Mass Index?. Retrieved September 27, 2018, from http://medind.nic.in/jav/t13/i2/javt13i2p101.pdf
Harvard Health Publishing. (2017). The Genetics of Heart Disease: An Update-Harvard Health. Retrieved from https://www.health.harvard.edu/heart-health/the-genetics-of-heart-disease-an-update
Lei, W., Wang, J., Wen, S., Yi, C., Hung, J., Liu, T., Chen, C. (2017). Risk of Acute Myocardial Infarction in Patients with Gastroesophageal Reflux Disease: A Nationwide Population- Based Study. Retrieved, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5358801/
Mancini, M. (2017). Aortic Dissection Clinical Presentation. Retrieved from https://emedicine.medscape.com/article/2062452-clinical
Physicians Committee for Responsible Medicine. (n.d.). Cholesterol and Heart Disease. Retrieved, from https://www.pcrm.org/health/health-topics/cholesterol-and-heart-disease
