Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is a 28 year old man who appears obese, presenting to the clinic with a one month history of chest pain.
HPI: The patient has had an uncomfortable feeling in the middle of his chest for the last month or so. It happens a couple of times a week, usually after eating, and once it woke him from sleep in the middle of the night – but it went away after he walked around for a bit. It doesn’t happen when he exerts himself – he rides his bike long distances, 20 or 30 miles at a time, and has never felt it then. It feels like a burning and an ache at the same time. Prior to a month ago he had never had similar pain before. If he has some on hand, Maalox seems to relieve the feeling, but often it will go away by itself if the patient sits up straight. The patient doesn’t feel it in his arms or jaw, but he vaguely feels something in his back when it happens. He denies feeling shortness of breath or sweating with the pain. He notices a dry cough that is minor, but annoying. He has no medical problems and his only medications are over-the-counter vitamins. He does not use alcohol, nicotine or illicit drugs. FMH: – Father alive, age 58, in good health. Mother alive, age 57, treated for hypothyroidism. One younger brother, age 25, in good health.
Vital Signs: BP 128/75, P 68, R 18, T 37 C, O2 96% on RA.
General: The patient is alert and oriented x3.
Skin: Normal. No rash.
HEENT: PERRLA. EOMI. Normal.
Pulmonary: Lungs CTAB. Normal effort. Breath sounds equal bilaterally.
Cardiovascular: RRR. No murmur. No chest-wall tenderness. Equal pulses and perfusion throughout. No sign of DVT. No edema. Blood pressure is equal in both arms.
Abdominal: Bowel sounds are normal. There is no abdominal tenderness. No rebound. No guarding. No bruising or skin changes, no caput medusa, liver edge is normal, negative Murphy sign. No splenic enlargement.
Back: No spinal tenderness, no muscular tenderness, no CVA tenderness.
Extremities: No edema, no calf tenderness, no discoloration.