Posted: July 26th, 2016
The!patient!is!a!pre%menopausal!43%year%old! female!seeing!you! for!an!initial! evaluation.!!Her!main!concerns!are!episodes!of!chest!pain!and!“flutterings”!in! her! chest.! ! These! episodes! are! not! clearly! related! to! exertion.! They! usually! occur! at work.! ! She! uses! a stair! master! for! 30! minutes! daily! and! the! symptoms!have!only!occurred once!or!twice!over!many!months!during!these exercise periods.!They!can!last!for!an!hour!or!two.!There!is!no!pleuritic, post% prandial!or!clear!positional/reproducible!component.!!She!noted!that!her!left! arm! felt! “numb”! after! waking! up! once! last! week! – this! took! 10! minutes! to! resolve.! The! palpitations! are! often! more! fleeting! in! nature! and! may! come! with!or!without!the!chest!pains.!!She!denies!specific!triggers!for!these,!such!as! caffeine,!exercise,!or!stress.!!Although!she!has!never!fainted!during!an!actual! episode! of! palpitations,! she! does! note! that! she! frequently! feels! dizzy! if! she! stands!up!too!quickly.!She!also!reports!frequent!headaches,!occasional!pains! in!her!neck!and!lower!back!and!a!“strange!ringing!in!my!ears!that!comes!and! goes”.!Headaches!are!often!in!conjunction!with!a!twitching!of!her!eyelid,!and! often!follow!a!night!of!poor!sleep.!She!is!concerned!about!developing!vascular! disease,!as!her!father!had!an!MI!at!age!60!and!her!mother!a!stroke!at!age!72.! The!patient!drinks!2!glasses!of!wine/night!and!does!not!smoke. Her! BP! is! 110/60,! HR! =! 62/min.! ! The! remainder! of! her complete! physical! exam!is!normal.!!She!seems!relieved!when!you!relate!this!fact.!She!states!that! she! has! been! frustrated,! as! previous! doctors! never! seemed! to! take! her! complaints!seriously. 4. What! is! this! patient’s! most! likely! unifying! diagnosis?! ! What! are the! differential diagnoses? 5. Please! describe! specific! management! strategies! you! would! employ! to! manage!this!patient!chronically.!!Would!you!consider!medications!or!other! interventions!at!this!point?!!How!frequently!should!you!see!her?!
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