Question

Mrs. S, a 78-year-old female, presents to the clinic complaining of difficulty catching her breath and persistent indigestion. She is a well-established patient at the clinic. With the exception of today’s visit, she describes her overall health as good. Her medical history includes hypertension, dyslipidemia (both well controlled with medications and lifestyle management), and osteoarthritis. Her surgical history consists of a Cesarean section 40 years ago and a total right knee replacement 5 years ago without complications. She is recently widowed and lives alone within a retirement community complex. She has 2 daughters and 5 grandchildren who live in different states. She is a nonsmoker and drinks 2–3 glasses of wine per month. Her physical activity is limited secondary to osteoarthritis of her knees and hips; but she participates in aquatic aerobics every Monday and Wednesday morning although, since her husband’s death 6 months ago, she has not been going regularly. She is actively involved in the retirement community, where she serves as a board member and is one of the social chairs for the clubhouse. Her mother, a lifelong smoker, died at age 65 from lung cancer; her father had a history of hypertension and died at age 80 from pneumonia. Her sister is a breast cancer survivor. There is no other significant family history. Upon review of systems, she reports fatigue, general weakness, and indigestion discomfort on and off for 2 weeks. Her indigestion typically lasts for 5–20 minutes. She has had bouts of heartburn that typically resolve with over-the-counter (OTC) antacids, but these have not helped lately. Within the past few days, she’s noticed shortness of breath (SOB), activity intolerance related to dyspnea on exertion (DOE), nausea, a nonproductive cough, and an epigastric/reflux burning sensation. Her chief complaints today are shortness of breath (SOB) and indigestion pain that does not radiate. She denies palpitations, headache, fever, chills, vomiting, and diarrhea. Her medications include losartan, 50 mg daily; lovastatin, 10 mg daily; naproxen, 250 mg twice daily as needed for pain. She is allergic to penicillin.

OBJECTIVE: Mrs. S is ambulatory, awake, alert and oriented x4. She is noticeably short of breath and appears anxious. Weight: 150 lb; height: 5 ft 4 inches; BP: 80/60; P: 106; T: 98.6; RR: 24. Chest/lungs: Diminished at bases although difficult to assess related to patient’s inability to take a deep breath due to discomfort. No chest tenderness on palpation. Cardiac: Rate irregular, tachycardic; S1, S2, and S4 sounds noted. Skin: Diaphoretic, cool.

ASSESSMENT: Myocardial infarction: Patient has many symptoms that indicate cardiovascular origin, including DOE, SOB, nausea, diaphoresis, and substernal burning discomfort. She has cardiac risk factors including hypertension, age, and dyslipidemia. Pneumonia: Mrs. S complains of fatigue, weakness, new onset of cough, and difficulty breathing, all of which point to possible respiratory infection. Older adults often do not present with classic symptoms of pneumonia that include fever, cough, and dyspnea. Sometimes the only indication is a change in the level of cognition.

Gastroesophageal Reflux Disease (GERD): She is exhibiting substernal burning pain and cough, which are signs and symptoms reflective of reflux. Chest pain from GERD can often imitate pain of a cardiac origin.

Anxiety/depression: The patient recently lost her husband. Shortness of breath, fatigue, and weakness could be a panic attack with possible underlying depression.

DIAGNOSTICS: EKG reveals some ST depression in leads V1 and V2 suggestive of posterior heart ischemia. Cardiac enzymes and CXR should be deferred to emergency department.

QUESTIONS 1. Does the patient’s psychosocial history impact how the clinician might treat this patient?

Answer 1