University of Puerto Rico

Medical Sciences Campus

School of Medicine
Department of Medicine

CASE PRESENTATION
Student's Name:

Raymond Rivera Vergara

Patient's Initials:

MRW

Student Number:

801-07-7280

Date of Encounter:

JAN 4, 2015

_________________________________________________________________________________
Chief Complaint:

" Me dio falta de aire y dolor de pecho"

History of Present Illness:

MRW is a 76 year old male with history of diabetes mellitus, CAD, intermittent claudication, hypertension and
hyperlipidemia presents to emergency department, with shortness of breath and chest pain, without radiation
to right arm, at center of chest. He describe the pain as a "constant pressure" with a value of a number 4.
Patient reports that the pain was accompanied by diaphoresis. Denied fever/chills, abdominal pain, diarrhea,
black or bloody stools and genitourinary complains.
Symptoms start on January 3 at 10pm at the casino, as usual and suddenly he heard a song that reminded him
of his wife that passed away. When this happened he started to feel down and extremely sad reason for which
he decided to go home. Later he found blood pressure above 200 systolic and took Lisinopril 10mg x 3.
Patient could not sleep due to chest pressure, denied taking other medication to relieve symptoms. Patient
continues feeling anxious and then decided to visit VA emergency room due to persistence of symptoms.
Patient refer cold sickness around 2 weeks ago, symptoms which produced productive cough with sputum,
cannot remember color phlegm. At time of ER examination, he was having suicidal ideas with plans.
SCXR done at ER could not rule out edema. Laboratories shows borderline elevated leukocytosis. Patient was
giving Saturation was 94%, elevated pro BNP was at 3202. ECG shows High degree of AV block with negative
chronotropism. at ER patient was ordered metroprolol, but it was never administrated and it was disconnected
examination it was discontinued.

Case Presentation - Page 2

Allergies:

NKDA

Childhood illnesses:

Diabetes Mellitus, , Bilateral, CAD, Intermittent Claudication, Hypertension, Hyperlipidemia

Adult medical history:

Gout, Esophageal Reflux, Exogenous Obesity, Sensorineural Hearing Loss

Medications (include doses): 1) Aspirin, 81 mg

2) Atarnovstatin 20 mg at bed time
3) Ranitidine 150mg at bedtime
4) Furosemide 10mg daily
5) Heparin 5000units/ 1ml
6) Insulin- regular, 100 units/ml 30 minutes before eating
10) Lisinopril 10mg Daily

Surgical history:
Family history:

No prior CHF, No prior MI, No prior CABG, No prior PCI, No prior Cardiac Cath,
No prior Valve Surgery, No prior Valve Treatment (TVT),
No prior Cardiac Transplant
No prior CHF, No prior MI, No prior CABG, No prior PCI, No prior Cardiac Cath,
No prior Valve Surgery, No prior Valve Treatment (TVT),
No prior Cardiac Transplant

Social history:
No history of tobacco, alcohol abuse or illicit drug use.

Review of systems:
Yes

No

SYSTEM

General:
Recent weight loss
Recent weight gain
Weakness
Fatigue
Fever
Chills

Skin:
Rashes
Lumps
Sores
Itching
Dryness

Yes

No

SYSTEM
Changes in skin color
Changes in hair
Changes in nails
Changes in size or color of moles

Head, Eyes, Ears, Nose & Throat

Headache
Dizziness
Lightheadedness
Loss of vision
Wears glasses or contact lenses
Eye pain
Redness of the eyes
Excessive tearing

Case Presentation - Page 3

Yes

No

SYSTEM

Yes

No

SYSTEM

Head, Eyes, Ears, Nose & Throat

Cardiovascular

Blurred vision

Paroxysmal nocturnal dyspnea

Double vision

Edema

Spots, flecks, flashing lights

Gastrointestinal

Loss of hearing

Trouble swallowing

Tinnitus

Heartburn

Vertigo

Loss of appetite

Earache

Nausea and/or vomiting

Ear discharge

Change in bowel habits

Frequent ear infections

Change in stool color

Frequent colds

Change in stool consistency

Nasal stuffiness

Pain with defecation

Nasal discharge

Rectal bleeding

Nosebleeds

Tarry black stools

Sinus pain

Hemorrhoids

Neck

Constipation

Swollen glands or lumps

Diarrhea

Goiter

Abdominal pain

Pain

Excessive belching

Stiffness

Excessive flatulence

Breasts

Jaundice

Lumps

Peripheral Vacular

Pain

Intermittent claudication

Discomfort

Leg cramps

Nipple discharge

Varicose veins

Respiratory

Ulcers

Cough

Past clots in veins

Sputum

Swelling of calves, legs or feet

Hemoptysis

Color change in fingertips or toes when cold

Dyspnea

Urinary

Wheezing

Increased frequency

Pleurisy

Nocturia

Cardiovascular

Urgency

History of heart murmurs

Burning or pain during urination

Chest pain or discomfort

Frequent urinary infections

Palpitations

Flank pain

Dyspnea on exertion

History of kidney stones

Orthopnea

Hematuria

Case Presentation - Page 4

Yes

No

SYSTEM

Yes

No

SYSTEM

Urinary (Male)

Neurologic

Reduced caliber or force of urinary stream

Changes in speech

Hesitancy

Changes in orientation

Dribbling

Frequent headaches

Genital (Male)

Dizziness

Hernias

Fainting or blackouts

Discharge from penis

Weakness

Sores or ulcers

Paralysis

Testicular pain

Numbness or loss of sensation

Testicular masses

Tingling sensation

Scrotal swelling

Tremors

History of sexually transmitted disease

Involuntary movements

Genital (Female)

Seizures

Irregular menses

Hematologic

Prolonged menses

History of anemia

Excessive bleeding

Easy bruising

Bleeding between periods

Excessive bleeding

Dysmenorrhea

Past transfusions

Menopause

Endocrine

Menopausal symptoms ("hot flushes")

Heat or cold intolerance

Postmenopausal bleeding

Excessive sweating

Vaginal discharge

Excessive sweat or hunger

Vaginal itching

Polyuria

Sores, ulcers or lumps

Changes in shoe or glove size

History of sexually transmitted diseases

Musculoskeletal
Muscle pain
Joint pain
Backache
Swelling of the joints
Stiffness of the joints
Muscular weakness
Limitation of motion
History of fractures or trauma

Psychiatric
Nervousness
Anxiety
Depressed mood

Health Maintenance:
Vaccinations
Hepatitis B

Last Dose
unknown

Influenza

unknown

Measles-Mumps-Rubella

unknown

Pneumococcal

unknown

Tetanus toxoid

unknown

Varicella

unknown

Case Presentation - Page 5

Health Maintenance:
Screening

Last Performed

Bone densitometry

Screening

Last Performed

Lipid profile

N/A

N/A

Colonoscopy

N/A

Mammography

N/A

Diabetes screening

N/A

Pap smear

N/A

Physical Exam:
Vital signs:

Temperature
Weight

Normal

Abnormal

97.6F
192

Heart rate
Height

52
5.8 ft

Respirations
BMI

SYSTEM

18
29.3

Blood pressure
Pain

138/60
0

ABNORMAL FINDINGS

General: Alert, awake, and oriented. Appropriate grooming

and hygiene. No acute distress.
Skin: Moist skin. No ulcers, rashes, or lumps. Normal hair
and nails. No jaundice.
HEENT: Normocephalic. Sclearea white. Normal visual
acuity. Pupils equally reactive to light. Normal eye fundi.
Normal ear canal. Weber midlince. Rinne AC>BC.
Normal nasal mucosa. No sinus tenderness. Moist oral
muscosa. Good dentition. No erythema or exudates.
Neck: No palpable masses or lumps. No goiter. Neck supple.
No palpable lymph nodes. No jugular venous distention. No
carotid bruits.
Thorax and Lungs: No tenderness to palpation of spinal
processes. Normal lung expansion. Normal tactile fremitus
No egophony or whispered pectoriloquy. Lungs clear to
auscultation with no ronchi, crackles or wheezing.
Breasts and Axillae: No lumps or masses. No discharge.
Heart: Non-displaced apex. Regular rhythm. Normal S1
and S2. No S3 or S4. No audible murmurs. No clicks, rubs
or other sounds.
Abdomen: Normal bowel sounds. No abdominal bruits
No tenderness to palpation. No masses. Normal liver span.
No splenomegaly. No ascites.
Extremities: No ulcers or discoloration. No edema.
Peripheral pulses +2 throughout. No deformities of the
joints. Normal range of motion. Normal muscle bulk and
tone.

Wheeze and decrease breath sounds

Right lower lungs

Case Presentation - Page 6

Normal

Abnormal

SYSTEM

ABNORMAL FINDINGS

Neurologic:
Mental status: Alert, awake, and oriented. Appropriate
speech. Normal mentation, insight, judgement, and memory.
Cranial nerves: Normal sense of smell. Normal visual
acuity, visual fields, and ocular fundi. Normal pupillary
reaction. Normal extraocular movements. Normal corneal
reflex, facial sensation, and jaw movements. Normal facial
movements. Normal hearing. Weber midline. Rinne AC>
BC. Normal swallowing and rise of the palate. Intact gag
reflex. Normal voice and speech. Normal shoulder and
neck movements. Normal tongue symmetry and position
Motor system: Normal muscle tone and bulk. Strength 5/5 in
all muscle groups. Point-to-point movements and rapid
alternating movements intact. Normal gait.
Sensory system: Normal sensation to pain, temperature,
light touch, vibration,and point discrimination.
Reflexes: Normal biceps, triceps, brachioradialis, patellar,
and Achilles deep tendon reflexes.

Laboratory Findings:

15.3
10.0

139

99

17.3

219
44.5

202
4.6

27

0.8

Segmented neutrophils

81.2 %

Aspartate dehydrogenase (AST)

13

Lymphocytes

10.8 %

Alanine dehydrogenase (ALT)

14

Eosinophils

2.8 %

Alkaline phosphatase

65

Monocytes

5.0 %

Bilirubin, total

0.79

Mean corpuscular volume

89.0fL

Bilirubin, direct

N/A`

Mean corpuscular hemoglobin

30.6pg

Magnesium

1.73

Other relevant laboratories:

Imaging studies:

Electrocardiogram:

Troponin 0.02 ng/mL.

Probnp elevated: 3202.

Chest X Ray Impression:

Compared with prior study, interval bilateral effusions and more
confluent opacities in the perihilar regions are seen which may
represent mild atelectatic and interstitial changes. In the
Sinus
rhythm with
high setting,
degree AV
with junctional
rhythm.
appropriate
clinical
mildblock
decompensated
heart
failureVent rate of
45bpm,
QRS
90ms,
QTc
394ms.
cannot be excluded however superimposed acute pneumonic process
cannot be excluded either. Follow-up is recommended.

Imaging Studies

Chest X Ray Impression:

Compared with prior study, interval bilateral effusions and more
confluent opacities in the perihilar regions are seen which may
represent mild atelectatic and interstitial changes. In the
appropriate clinical setting, mild decompensated heart failure
cannot be excluded however superimposed acute pneumonic process
cannot be excluded either. Follow-up is recommended.

Case Presentation - Page 7

Assessment:

MRW is a 76 year old male with history of diabetes mellitus, CAD, intermittent claudication, hypertension and
hyperlipidemia presents to emergency department, with shortness of breath and chest pain. was evaluated
today at bed side. Vital signs were evident of bradycardia. Physical exam were positive for left basilar
crackles, abdominal hernia, and benign rest of exam. ECG with high degree AV block, negative
chronotropism. Patient at the moment asymptomatic, referring he was feeling better than when he arrived.
Labs with leukocytosis, stable hemoglobin and platelets. Chem profile with stable renal function and no major
electrolyte abnormalities. Probnp elevated at 3202. Due to AV block, patient was started on telemetry, and
bedside cardiac defibrillator on pacemaker mode placed.

Base on clinical and ECGs findings, most likely diagnosis is AV complete block. Patient with fatigue and
dyspnea that could be secondary to this block. Patient's previous ECGs showes rates over 60s and without
AV block. Patient at the moment of evaluation at IM ward referred no symptoms and had stable vital signs
despite bradycardia. Treatment is pacemaker placement. Therefore temporarily a bedside monitor in
pacemaker placed. Patient had metoprolol ordered at the ER, however never administered, it was quickly
discontinued.
Patient could also develop a panic attack, patient with shortness of breath that started after inciting event of
his dead wife's memories. In association with extreme nervousness, feeling of wanting to die, and lack of
sleep. Patient's wife died 4 months ago, which put him in a labile state, precipitating panic panic attack.
Patient's elevated blood pressure episode can be related to emotional stressor, and is now resolved. Patient
did express feeling extremely sad and having ideas of killing himself by stepping up a stairway he has at
home and throwing himself down. Therefore patient started on constant observation and psychiatry
consulted.
Differential diagnose could be CHF or CAP base on CXR possible edema on the lungs. However, patient did
not present with volume overload (JVD, bilateral crackles, peripheral edema) and could lay down in his bed
flat in supine position. CAP is also unlikely because patient denied cough, he has not had fever, however, he
does present with borderline high leukocytosis. CXR does not rule out any infectious or effusion. Therefore
base on the lack of CAP symptoms, antibiotics were not ordered.
Echocardiogram was ordered. Last echo from 2010 with preserved diastolic and systolic function.

Plan:

Planned Procedures: Permanent Pacemaker, vitals every 8 hours, limit activity to bed rest diet should be
lower in sodium measure input and output of liquid, continue monitoring electrolytes and consult cardiology
for echo-cardiogram and possible pace maker.

References:

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