Identifying Patterns of Illness and Wellness Case Study:

Identifying Patterns of Illness and Wellness Case Study:
Informant: Patient. Reliable and a good historian.
Chief Complaint: J.K. is a 75 year-old female with normal mental status who presents to the ED at NY Medical Center (NYMC) with complaints of substernal “toothache like” chest pain of 12 hours duration.

History of Present Illness:
J.K. is a retired nurse with a history of hypertension. She was well until 11pm on the night prior to admission when she had an onset of “aching pain under her breast bone” while sitting and watching television. The pain was described as “heavy” and “toothache” like. It was not noted to radiate, nor increase with exertion. She denied nausea, vomiting, diaphoresis, palpitations, dizziness, or loss of consciousness. She took 2 tablespoon of antacid without relief, but did manage to fall sleep. In the morning, she awoke free of pain, however, upon walking to the bathroom, the pain returned with increased intensity. At that time, she called her daughter, who told her to take an aspirin and brought her immediately to the emergency room.
Past Medical History:
1998: Diagnosed with hypertension. Well-controlled on diuretic therapy.
1990: Diagnosed with peptic ulcer disease. Resolved after three months on cimetidine.
2005: Admitted to NYMC with presenting s/s of intermittent mid-sternal chest pain. EKG demonstrated 1st degree AV block and CXR showed mild pulmonary congestion with cardiomegaly. MI was ruled out.
2013: ED visit. MI was ruled out. Diagnosed with mild CHF.
Allergies: Penicillin; experienced rash and hives x 20 years.

Past Hospitalizations:
1999: Gastrointestinal hemorrhage (GI Bleed)
2005: Chest pain. MI was ruled out. 1st degree AV block.

Surgical History:
Normal childbirth (NSVD) x 5
1995: Total abdominal hysterectomy and bilateral oophorectomy for uterine fibroids
1998: Bunionectomy – left foot

Social History:
Alcohol use: 1 or 2 beers each weekend; 1 martini before dinner each night
Tobacco use: 2 packs/day x 40 years; quit 2 years ago

Current Medications:
Digoxin 0.125mg PO once daily
Enalapril 20mg PO twice daily
Lasix 40mg PO once every other day
Kcl 20mg PO once daily
Tylenol 2 tabs twice daily as needed for arthritis
Occasional ibuprofen (Advil) for headaches
Miralax for chronic constipation

Family History:
Mother: 79 and deceased – breast cancer
Father: 54 and deceased – heart attack, HTN
Siblings: two brothers
– One diagnosed with diabetes (Type II) at age 40
– One diagnosed with HTN at age 45
Children: 2 sons, ages 50 and 58 and 3 daughters, ages 42, 46, and 48 all alive and well

Past Health Maintenance:
Infectious Diseases: Usual childhood illnesses. No history of rheumatic fever
Immunizations: Flu vaccine annually. Pneumovax 2006
Transfusions: 4 units received in 1999 for GI hemorrhage; transfusion complicated by
Hepatitis B infection.
Mammogram: 10 years ago – negative
Colonoscopy: 7 years ago – significant for polyps and multiple diverticula
Pap test: 1994 significant for cervical dysplasia
Bone density Test: 8 years ago significant for early osteoporosis

Since her last admission in 2005, she reports seeing her Primary Care Physician annually and her Cardiologist every 3 months. She has recently tested negative for diabetes and her liver enzymes have been within normal limits. She describes a stable two-pillow orthopnea, dyspnea on exertion after walking two blocks, and a mild chronic ankle edema, which is worse with prolonged standing. She denies syncope, recent chest pain or paroxysmal nocturnal dyspnea.
She reports eating out at the local Thai and Chinese restaurants frequently. She cooks for herself but does not restrict her diet as she feels she “is too thin”
She reports little exercise due to severe knee pain.

Systems Review:
Constitutional: weight 115 lbs. with recent weight loss; height 5’8”
HEENT: No headaches
Eyes: wears reading glasses but thinks vision getting is worse, no diplopia or eye pain
Ears: hearing loss for many years, wears hearing aid Nose: no epistaxis or obstruction;
no history of tonsillitis or tonsillectomy.
Wears full set of dentures for more than 20 years, works well.
Respiratory: No history of pleurisy, cough, wheezing, asthma, hemoptysis, pneumonia, pulmonary emboli, TB or TB exposure
Cardiac: CHF (see HPI)
Vascular: No history of claudication, gangrene, deep vein thrombosis, aneurysm.
Has chronic venous stasis skin changes
G.I.: Admitted to NYMC in 1999 after two days of melena and hematemesis.
Upper G.I. series was negative but endoscopy showed evidence of gastritis, presumed to be caused by ibuprofen intake. Her hematocrit was 24% on admission and she received four units of packed cells. Last colonoscopy revealed multiple diverticula. Since then her stool has been brown and consistently hematest negative when in clinic. Several months after this admission she was noted to be mildly jaundiced and had elevated l
iver enzymes. At this time it was realized that she contracted hepatitis B from transfusions. Since then she has not had any evidence of chronic hepatitis.
GU: History of several episodes of cystitis, most recently E Coli 3/1/99, treated with Bactrim. Reports dysuria in the 3 days prior to hospitalization. No fever, no hematuria. No history of sexually transmitted disease. Menarche was at 15, menstrual cycles were regular interval and duration, menopause occurred at 54. Seven pregnancies with 5 normal births and 2 miscarriages.
Neuromuscular: Osteoarthritis of both knees, shoulder, and hips for more than 20 years. Took ibuprofen until 1999, has taken acetaminophen since her GI bleed with good relief of intermittent arthritis pain. There is no history of seizures, stroke, syncope, memory changes.
Emotional: Denies history of depression, anxiety.
Hematological: no known blood or clotting disorders.
Rheumatic: no history of gout, rheumatic arthritis, or lupus.
Endocrine: no known diabetes or thyroid disease.
Dermatological: no new rashes or pruritus.
Labs / Diagnostic studies:
CBC: WBC 12,400; Hgb 12.0; Hct 38.0; MCV 80.0; Plts 218,000; Retic 1.3
BMP: Na 143; K 4.1; Cl 103; CO229; Glu 102; BUN 9; Creat 0.8
LFT: T bili 0.5; Alk Phos 155; AST 55; ALT 26; LDH 274; Total Cholesterol 201 (she was unaware of previous levels until today); Triglycerides 299
U/A: SG 1.008 pH 6.5 2+ Alb many WBC many RBC 3+ bacteria
ABG: pH 7.46 pCO234 PO284 O2Sat 98% (room air)
CPK: 480
MB fraction: positive
Troponin: 25
EKG: NSR 96, ST elevations I, AVL, V4-V6; rare unifocal PVC’s
CXR portable AP: probable cardiomegaly, mild PVC