FractureFixer

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19 y/o Caucasian male presents to ED with the following symptoms:

--Substernal chest pain localized medially and also on the left side
--Nausea/upset stomach w/o vomiting lasting over 3 months, with treatment with PPI over the last 3 weeks ineffective

Pt rates chest pain 7/10 and getting gradually worse over the last 2 days. Pain is bad enough to prevent sleep. Pt reports not having an appetite and has not ate much the last few days.

Past medical history:
Pt reports no history of heart problems except a heart murmur about 5 years ago. Family history of stroke, afib, and peptic ulcer. Pt denies sob, syncope, and diarrhea. Pt has had gastritis in the past and has been on PPI for the last 3 weeks - month without much improvment. Pt has tried Prilosec, AcipHex, and is currently on Nexium which he reports as having worked in the past, but not at this time. Pt tested negative for H. pylori (blood test) about 14 months ago. Pt has hx of costochondritis.

Pt also reports an episode about 2 weeks back while on vacation. Pt suddenly became lightheaded, dizzy, and nauseous. Pt reported to nearby ED and was treated with IV Zofran, which cleared it up. After leaving the ER, pt reports feeling a discomfort on the left side of chest. Pt said it was not a pain, but felt like "butterflies" in his heart. Pt reports feeling pulse and noticing PVCs, and suddenly lost all energy. Figuring it was just a reaction to the Zofran and not wanting to go back to the ER, pt reports sleeping for about 24 hours straight before the feeling finally went away. Ever since, the pt hasn't felt "right".

Current medications:
Nexium QAM
Lexapro (anxiety) QAM
Zyrtec QHS
Carafate QAC and QHS
Tums prn for stomach upset
Pepto-Bismol prn for stomach upset
Tylenol prn for pain
Phenylephrine prn for congestion

Vitals normal. Chest x-ray and CT scan both clear. EKG normal. CBC profile all normal. Some chest tenderness noted. Chest pain cleared with Lortab PO and Toradol IVP. Nausea cleared with Zofran IVP, but pt does not report side effects this time.
----

Thoughts? Opinions?
He has you as a doctor!:laugh:
 

Scaredshizzles

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19 y/o Caucasian male presents to ED with the following symptoms:

--Substernal chest pain localized medially and also on the left side
--Nausea/upset stomach w/o vomiting lasting over 3 months, with treatment with PPI over the last 3 weeks ineffective

Pt rates chest pain 7/10 and getting gradually worse over the last 2 days. Pain is bad enough to prevent sleep. Pt reports not having an appetite and has not ate much the last few days.

Past medical history:
Pt reports no history of heart problems except a heart murmur about 5 years ago. Family history of stroke, afib, and peptic ulcer. Pt denies sob, syncope, and diarrhea. Pt has had gastritis in the past and has been on PPI for the last 3 weeks - month without much improvment. Pt has tried Prilosec, AcipHex, and is currently on Nexium which he reports as having worked in the past, but not at this time. Pt tested negative for H. pylori (blood test) about 14 months ago. Pt has hx of costochondritis.

Pt also reports an episode about 2 weeks back while on vacation. Pt suddenly became lightheaded, dizzy, and nauseous. Pt reported to nearby ED and was treated with IV Zofran, which cleared it up. After leaving the ER, pt reports feeling a discomfort on the left side of chest. Pt said it was not a pain, but felt like "butterflies" in his heart. Pt reports feeling pulse and noticing PVCs, and suddenly lost all energy. Figuring it was just a reaction to the Zofran and not wanting to go back to the ER, pt reports sleeping for about 24 hours straight before the feeling finally went away. Ever since, the pt hasn't felt "right".

Current medications:
Nexium QAM
Lexapro (anxiety) QAM
Zyrtec QHS
Carafate QAC and QHS
Tums prn for stomach upset
Pepto-Bismol prn for stomach upset
Tylenol prn for pain
Phenylephrine prn for congestion

Vitals normal. Chest x-ray and CT scan both clear. EKG normal. CBC profile all normal. Some chest tenderness noted. Chest pain cleared with Lortab PO and Toradol IVP. Nausea cleared with Zofran IVP, but pt does not report side effects this time.
----

Thoughts? Opinions?
Drug abuse/social issues, anxiety attacks, hypochondriasis, other psychiatric disorders NOS.

The only other thing to do medically would be to scope him I suppose. You can think outside of the box and consider some sort of weird hormone secreting tumor...Was the CT scan he had of the abdomen or of the chest?
 

doogoshly

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first thing i'd check is her cardiac enzymes (i don't see that mentioned anywhere) to rule out MI bc it can be silent in esp in women. i know she's only 19 but can never be sure. with her fam hx of afib and stroke and her "butterflies," i'd look at an echo too. but then again, with a hx of costochondritis, if the pain is strictly localized, it could be another case of that. shrugs.
 

Jamers

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first thing i'd check is her cardiac enzymes (i don't see that mentioned anywhere) to rule out MI bc it can be silent in esp in women. i know she's only 19 but can never be sure. with her fam hx of afib and stroke and her "butterflies," i'd look at an echo too. but then again, with a hx of costochondritis, if the pain is strictly localized, it could be another case of that. shrugs.
I agree, echo but I would also make him wear a halter for a month. He could easily be feeling an arrhythmia as "butterflies."
 

J-Rad

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Methinks someone is seeking medical advice. Methinks someone should go see their doctor. The scenario provided does not sound entirely consistent with the common benign things that cause chest pain in an adolescent male. And even the benign things that cause chest pain in an adolescent male may be amenable to evaluation/treatment by a qualified physician with whom you have a patient physician relationship. That does not include posters on a semi-anonymous internet chatboard.
Non-medical advice: read "How Doctors Think" by J. Groopman. It offers some wise advice on how to be an empowered patient (read empowered, not "entitled"). An important question to ask is "what else could this be?". There is a wider differential diagnosis in the OP's scenario than has been addressed in this cursory thread, and I have the feeling that this is not the appropriate venue (real life, with real life doctor is).
 

J-Rad

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I agree, echo but I would also make him wear a halter for a month. He could easily be feeling an arrhythmia as "butterflies."
Only in the farmlands of Iowa (http://www.thefreedictionary.com/halter) ;)
It's "Holter" (after Norman). It's OK, I come from the land where one has "prostrate cancer" and you go see a "gastrologist" for your tummy problems:p
 

Krisss17

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19 y/o Caucasian male presents to ED with the following symptoms:
first thing i'd check is her cardiac enzymes (i don't see that mentioned anywhere) to rule out MI bc it can be silent in esp in women. i know she's only 19 but can never be sure. with her fam hx of afib and stroke and her "butterflies," i'd look at an echo too. but then again, with a hx of costochondritis, if the pain is strictly localized, it could be another case of that. shrugs.
Doogoshly, sorry for pointing out the obvious...but if you looked at the very sentence, you'd see that it is a male not a female.
 

TakayaSue

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OK. I can confidently state that what's wrong with this patient is, "not an MI!" It sounds like he's had fairly extensive workups, with nothing positive and no real risk factors (e.g. not a smoker, cocaine user, FHx c/w Romano Ward, EKG c/w Brugada or Romano Ward, or IHSS, or MVP, etc.). To complete his cardiac workup, he needs some sort of loop or event recorder, e.g. a Holter. He also needs a tox screen to ensure he is not on cocaine or other sympathomimetics. Serial EKG's and cardiac enzymes over 6-8 hours while he is having symptoms would complete the rule out.

To complete his GI workup, he needs an EGD or an esophageal pH probe. Amylase/lipase, alk phos, TBili, etc. should have been ordered along with the cardiac enzymes in his first round of labs. A RUQ U/S is only part of the workup if these enzymes are abnormal or if the patient has a positive Murphy's on a exam or a story c/w biliary disease. This further testing will likely be negative. There is no reason to suspect Z-E syndrome (and to test gastrin/secretin levels) without a demonstrable lesion in his esophagus, stomach, or small bowel (e.g. erosions or ulcers). Similarly, without evidence of malabsorbtion, no reason to chase Whipple's disease, tropical sprue, lactose intolerance, celiac sprue, etc. I'm assuming that even though the CT was for r/o PE and r/o aortic dissection, the radiologist would have commented if the patient had a fixed hiatal hernia or other anatomic anomaly.

As far as your proposed management goes:

1. A PPI is all someone without a demonstrated lesion needs -- carafate and H2RA's are redundant. Frankly, I usually send these people out with famotidine and only switch to a PPI if they fail famotidine tx.

2. It is poor form to give a drug as strong as Lortab for gastritis/costochondritis. If he really wants Lortab, he should have an x-ray or physical exam c/w a rib fx, not with vague dyspepsia or palps. Even GI cocktails are not really something you want people gonig home with (if they include viscous lidocaine) -- they are not entirely benign.

3. Pepto Bismol (and Kayopectate since 2004, for that matter, which is now also bismuth subsalicylate based) are not bad drugs for occasional use. The guy has normal blood counts and rectal exam, so why suspect that he's gonna have melena and we're gonna miss it.

4. I've never seen a significant side effect from Zofran -- I don't even know why you think dysequilibrium/pre-syncope could be attributable to that. I would be nervous about sending someone home with a month of Zofran -- it's a benign drug, but is he vomiting that much? Before you send someone home on a month of Zofran, you need to r/o CVS, SMA syndrome, gastric outlet obstruction, pancreatitis, hyperemesis gravidarum, myocardial infarction, etc. Same reason I don't send these people home with Lortab. Either you think they're symptoms are BS and they can go home with nothing, or else you think they have real symptoms and need a further workup -- a month of Zofran is rarely the right answer.

5. I agree. 7/10 chest pain can't be hypochondriasis. Good point. Everyone knows that any pain score greater that 4.75 has to be a surgical lesion. :laugh: Jesus! Does anyone really think that pain score is acutally a vital sign? I send people home with a pain score of 12/10 all the time. But I've never discharge someone with a HR of 130 or an SaO2 of 80% -- because those are real abnormal vital signs...

6. F/U with PCP. :xf:

Thanks for the feedback. BTW this is not a real pt, just an assignment. Just looking for some opinions to see if I was missing anything.

My dx:

Current chest pain ruled likely noncardiac. The previous episode of chest discomfort could have been afib or atrial flutter, but current auscultation, EKG, chest xray and CT are all normal with no arrythmias or blockages. If pt feels these symptoms again, pt is to report to closest ED immediately.

Pt should continue taking Nexium and Carafate. Added script for Zofran (month supply) to help with nausea/vomiting and Lortab (week supply) for pain. Also added docusate to prevent constipation/abdominal pain resulting from Lortab use. Advised that applying thera-gesic cream to tender area 2-4 times daily may provide some relief. Pt is to return to ED immediately if chest pain worsens, pain radiates down left arm, or if shortness of breath or syncope develops. Pt is also to report to local ED if severe abdominal pain develops or if black, tarry stool is noticed. Advised patient to stop taking Pepto-Bismol OTC as black stool is a side effect.

Ordered f/o upper endoscopy and labs for fasting gastrin/secretin due to Zollinger-Ellison suspicion. Also added labs for amylase/lipase with abdominal ultrasound to check for pancreatitis (although baseline WBC was normal) and also to check for any stones or blockages.

Pt is to f/o in 7 days for results. May order lower endoscopy and possible 30-day holter monitor to check for paroxysmal afib at that time.

A few questions:

Would it have been a more prudent step to treat presenting chest pain with a GI cocktail first rather than Lotab, even though the pt is not presenting as a "drug seeker"??

Also, would some of you really dismiss a pt with 7/10 chest pain from the ER with a dx of hypochondriasis? Amazing...
 

jbp100

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Also, on second thought, another H. pylori test (both blood and breath) wouldn't hurt since the pt hasn't had one in over a year and a false negative is not out of the realm of possibility.
You may consider running stool antigens for H. Pylori since this is the gold standard for diagnosis.
 

J-Rad

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hahah halter holter same difference.
Come on, man, you gotta admit, from an Iowa-farm humor perspective, that's an amusing mistake given the def. of "halter". This is why (sincerely) I love Iowa. :)

Back to the OP: I'm sorry, I'm still suspicious of a new poster, "pre-pharmacy" would have that level of detail and knowledge of a case and be asked to develop such an in depth DDx/treatment plan...but I guess that's just me.

But there are some learning points in this case: it may be beneficial to frame the clinical scenario in a formal way: "The differential diagnosis of substernal chest pain in a 19 year old caucasian male with a past medical history significant for a recent episode of palpitations (BTW, the patient does not know if they were PVCs) and near-syncope, treatment refractory "gastritis", and anxiety disorder is..."
When formulating the DDx I like to break it into "common" and "things that will potentially kill the patient [ED folk probably break the latter into "quickly" and "less quickly". Just because the common things are common doesn't mean that uncommon things don't happen. Common benign conditions tend to have common patterns and lack more ominous features. This case begs those questions to be asked.
Another point is that ROS, Hx, and PE should drive the workup. Unfortunately as medicine becomes more time-crunched a good ROS is often the first thing to go.
BTW, a lot of the responses have seemed to come from an internal medicine perspective, but remember the pt. in this scenario is 19-basically a pediatric patient and the DDx and treatment recommendations are often somewhat different between peds and IM (Ex. a scope in a 19yo? What if it can be clinically diagnosed as functional abdominal pain? Common dx in peds. Also Afib in a 19yo w/o a h/o congenital heart disease? Not as likely as other things).

The furthest I'm willing to go into the DDx (given my suspicion of the post) is that I would put together general categories of most likely systems to be the causative source:
Psych
Cardiac
GI
MSK
H/O
 

J-Rad

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I agree with some of the stuff you have said, but I don't think a scope is too out of the ordinary, even if the pt is 19 y/o. There are many GI disorders with very similar symptomology. Why not take a look? Also, I have seen scopes done on pts at this age or near many times -- not uncommon.

Yes, lots of kids and adolescents get scopes, but "why not take a look" is a dumb reason and a mentality that is no small reason behind high health care costs. Why not do full body CT scans and $1000 "executive workups" on everyone as well? Many conditions can be diagnosed by clinical history and PE alone with minimal to no lab/radiology by a primary care physician with good clinical accumen. The internist who sees the 65 year old with GERD wants the scope to rule out Barret's. That isn't highly likely in this patient. If the clinical story lends itself to scoping, fine, but tests for tests' sake is poor medicine.


I agree that afib is unlikely, but given fhx and the fact that the pts description is c/w with this dx makes it something that is definitely worth checking into. As you said, just because something is uncommon doesn't mean it doesn't happen.
Arrhythmia-yes. Very worth looking into. A 24hr Holter-pretty reasonable. The likelihood it will be AFib-not high. My bone of contention is with the presumption that AFib is a likely culprit; there are more likely arrythmias in this patient population. One huge thing that has not been ruled out is heart failure. HF can present with this constellation of symptoms. Echo is a reasonable study.
.
 

Scaredshizzles

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This reminds me that we don't even have vital signs to go off of here....If you're considering something like DCM from drinking heavily or whatever, a low blood pressure in this patient would certainly make me consider it a little bit more...


As far AFib....I think if you're just going based on palpitations, something like PVCs would be more likely...occasionally even young people can have a significant enough run of PVCs to take notice. And if they feel like their heart is racing, then certainly something like a short run of SVT is much, much more likely than Afib in a young patient like this.
 

Rendar5

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...I sitll dont' get how the patient felt pvc's. That's not something in a history, that's something on an EKG. (es I realize that palpitations may commonly be PVC's.

Things to keep in mind: Zofran can cause akithisia. This is not uncommon by any means. I have seen it, heard about it, and have had that specific question come up on my step 2's. This story doesn't fully sound like any akithisia though.

Afib in a young patient is extremely unlikely as is MI without major underlying disease. Afib may appear as holiday heart, but nothing in the history suggests this.

Cardiac disease leading to ischemia is also every unlikely in a 19yo unless the patient has a rare vascular abnormality, or has been unlucky with cocaine abuse.

A drug screen on this patient will also be useless. There is nothing in a drug screen that would make me change my workup or management. He is taking phenylephrine and is already likely to have false-positives. Though i do have to double-check if it cross-reacts with the cocaine screen. How much sudafed is this guy taking anyway?

I agree that CHF may be something to consider, but take a closer look at history and physical before going there. (specifically, orthopnea and elevated JVP are very sensitive symptoms and signs). If he doesn't have this or a heart murmur at the time of exam, I'd think an echo may be a waste of time.

I know someone here said his rectal exam was normal? I didn't notice that n the patient's history. The patient gets a finger up the bum. Although normal CBC, so is there really reason to suspect a zebra like Zollinger-Ellison?

I also see little reason to order anything to look for H. Pylori. He's already being treated enough that he shoudln't be symptomatic just from that. If he does in fact have ulcers, it's from some other cause.

To the OP: a couple flaws in your reasoning and plan: u/s is great for looking at the gallbladder, but ****ty for looking at the pancreas. CT is the better study to look for pancreatitis (not that I'm thinking this kid gets one). Also, a family hx of afib does not mean anything unless it was specifically at a young age, if even then. If his grandpa got afib when he was 80, does that really mean anything for a 19yo?

Personally (1st year resident here), I'd get a repeat EKG, Holter monitor, and get a more complete set of basic labs (none of the expensive ones), and I'd get a more complete physical exam including rectal, consider endoscopy, but no rush to one without more information. If I had this patient in the ED, I'd just do a quickie u/s too. would only take a couple minutes at most. But this is not the case to get diagnosed in the ED, it'll get diagnosed outpatient or by GI (or psych).
 

Aznfarmerboi

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19 y/o Caucasian male presents to ED with the following symptoms:

--Substernal chest pain localized medially and also on the left side
--Nausea/upset stomach w/o vomiting lasting over 3 months, with treatment with PPI over the last 3 weeks ineffective

Pt rates chest pain 7/10 and getting gradually worse over the last 2 days. Pain is bad enough to prevent sleep. Pt reports not having an appetite and has not ate much the last few days.

Past medical history:
Pt reports no history of heart problems except a heart murmur about 5 years ago. Family history of stroke, afib, and peptic ulcer. Pt denies sob, syncope, and diarrhea. Pt has had gastritis in the past and has been on PPI for the last 3 weeks - month without much improvment. Pt has tried Prilosec, AcipHex, and is currently on Nexium which he reports as having worked in the past, but not at this time. Pt tested negative for H. pylori (blood test) about 14 months ago. Pt has hx of costochondritis.

Pt also reports an episode about 2 weeks back while on vacation. Pt suddenly became lightheaded, dizzy, and nauseous. Pt reported to nearby ED and was treated with IV Zofran, which cleared it up. After leaving the ER, pt reports feeling a discomfort on the left side of chest. Pt said it was not a pain, but felt like "butterflies" in his heart. Pt reports feeling pulse and noticing PVCs, and suddenly lost all energy. Figuring it was just a reaction to the Zofran and not wanting to go back to the ER, pt reports sleeping for about 24 hours straight before the feeling finally went away. Ever since, the pt hasn't felt "right".

Current medications:
Nexium QAM
Lexapro (anxiety) QAM
Zyrtec QHS
Carafate QAC and QHS
Tums prn for stomach upset
Pepto-Bismol prn for stomach upset
Tylenol prn for pain
Phenylephrine prn for congestion

Vitals normal. Chest x-ray and CT scan both clear. EKG normal. CBC profile all normal. Some chest tenderness noted. Chest pain cleared with Lortab PO and Toradol IVP. Nausea cleared with Zofran IVP, but pt does not report side effects this time.
----

Thoughts? Opinions?
I recommend putting this patient on H. Pylori treatment. This person has constant dyspepsia and although I am not a physician, a blood test negative does not mean there is no H. Pylori. Endoscopy is gold standard here. Endoscopy can be kind of expensive so might as well just treat.

I would also recommend getting acetaminophen levels.
 

Scaredshizzles

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...I sitll dont' get how the patient felt pvc's. That's not something in a history, that's something on an EKG. (es I realize that palpitations may commonly be PVC's.

Things to keep in mind: Zofran can cause akithisia. This is not uncommon by any means. I have seen it, heard about it, and have had that specific question come up on my step 2's. This story doesn't fully sound like any akithisia though.

Afib in a young patient is extremely unlikely as is MI without major underlying disease. Afib may appear as holiday heart, but nothing in the history suggests this.

Cardiac disease leading to ischemia is also every unlikely in a 19yo unless the patient has a rare vascular abnormality, or has been unlucky with cocaine abuse.

A drug screen on this patient will also be useless. There is nothing in a drug screen that would make me change my workup or management. He is taking phenylephrine and is already likely to have false-positives. Though i do have to double-check if it cross-reacts with the cocaine screen. How much sudafed is this guy taking anyway?

I agree that CHF may be something to consider, but take a closer look at history and physical before going there. (specifically, orthopnea and elevated JVP are very sensitive symptoms and signs). If he doesn't have this or a heart murmur at the time of exam, I'd think an echo may be a waste of time.

I know someone here said his rectal exam was normal? I didn't notice that n the patient's history. The patient gets a finger up the bum. Although normal CBC, so is there really reason to suspect a zebra like Zollinger-Ellison?

I also see little reason to order anything to look for H. Pylori. He's already being treated enough that he shoudln't be symptomatic just from that. If he does in fact have ulcers, it's from some other cause.

To the OP: a couple flaws in your reasoning and plan: u/s is great for looking at the gallbladder, but ****ty for looking at the pancreas. CT is the better study to look for pancreatitis (not that I'm thinking this kid gets one). Also, a family hx of afib does not mean anything unless it was specifically at a young age, if even then. If his grandpa got afib when he was 80, does that really mean anything for a 19yo?

Personally (1st year resident here), I'd get a repeat EKG, Holter monitor, and get a more complete set of basic labs (none of the expensive ones), and I'd get a more complete physical exam including rectal, consider endoscopy, but no rush to one without more information. If I had this patient in the ED, I'd just do a quickie u/s too. would only take a couple minutes at most. But this is not the case to get diagnosed in the ED, it'll get diagnosed outpatient or by GI (or psych).

You feel PVCs because the beat after the compensatory pause allows for a long diastolic filling period and you get a really large volume of blood being forced into the aorta with the next beat.....which some patients feel..(Stretch receptors and what not.)

I believe while Reglan can cause akathesias, Zofran really cannot or at least should not (anything can do anything in any particular patient I suppose)....Although I've heard some attendings even think of Zofran. Reglan has anti-dopaminergic activity, zofran does not.

.
 

Rendar5

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You feel PVCs because the beat after the compensatory pause allows for a long diastolic filling period and you get a really large volume of blood being forced into the aorta with the next beat.....which some patients feel..(Stretch receptors and what not.)

I believe while Reglan can cause akathesias, Zofran really cannot or at least should not (anything can do anything in any particular patient I suppose)....Although I've heard some attendings even think of Zofran. Reglan has anti-dopaminergic activity, zofran does not.

.
Reglan I know produces akathisia, but that is not the drug that caused akithisia in the patient I know (because they asked for it and got a different anti-emetic instead). I'm pretty sure it was zofran, but it may have been some other common anti-emetic I can't think of at the moment. I forget it was an anti-serotinergic and not an anti-dopaminergic.

My point about the PVC wasn't about mechanism, since I do know how it causes palpitations. My point was that a patient isn't going to be walking on the street, have a palpitation, and say "oh I just had a PVC" (because even if they know the term, they're not going to know whether it was a PVC or something else)
 
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Rendar5

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I also agree SVT would be more likely than afib, but what about the "butterflies" the pt described? Seems more c/w afib or flutter to me, unless it is anxiety induced.
SVT, intermittent VTach, PVCs, PAC's, anxiety (no arrhtymia or sinus tach), and maybe a 2nd degree heart block are all more likely causes of palpiations than Afib or AFlutter in a 19yo guy without an obvious cause (a weekend binge of booze, for example). Afib probably woudln't even cause palpitations unless it were a rapid conductor.

What's common is common. Don't go looking for zebras. If it's a strange story and doesn't fit with any standard presentations, then an atypical presentation of something common is also much more likely than a standard presentation of a zebra.

For example, if you see a guy come in with hemoptysis and hematuria, 90% of the time it's still not going to be Goodpasture's disease, it's going to be Wegener's.
 

TakayaSue

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Reglan I know produces akathisia, but that is not the drug that caused akithisia in the patient I know (because they asked for it and got a different anti-emetic instead). I'm pretty sure it was zofran, but it may have been some other common anti-emetic I can't think of at the moment. I forget it was an anti-serotinergic and not an anti-dopaminergic.
Probably Compazine or Fenergan (or Propulsid or droperidol, if this story was from several years ago). Zofran/Kytril are really specific to the 5HT receptors and are not known to cause akasthisa or dystonia.

Re: Zantac vs. Pepcid -- no difference in my book -- whatever the hospital has on formulary. Cimetidine (Tagamet) is the only one to avoid b/c of all the CYP450 issues.
 

TakayaSue

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Thank you for the response. A few questions -- what are the chances cardiac enzymes would remain elevated 3 weeks to a month after the event? As I mentioned in the OP, the "butterflies" occured 3-4 weeks prior to the ED visit and were accompanied by severe fatigue, drowsiness, anxiety, tachycardia, PVCs, and lightheadedness.
In the absence of an elevated creatinine level, there should not be an elevated Troponin-I 3 weeks after an event.

1. Yes, a Nexium/Carafate combination may be a duplication in drug therapy but they do exhibit different mechanisms of action and if the PPI has been ineffective thus far, throwing in Carafate or an H2 would not be hurting anything.
Theoretically, you are right. In practice, once I start using "big guns" or a multi-drug reigmen, I want to know what I'm treating. A condition that is refractory to the first line of usual therapy is often the first clue that you need to reconsider your proposed diagnosis.

2. I know a GI cocktail probably wouldn't be necessary as an outpatient script in this case, but I was curious about its use in EDs to help confirm that chest pain is epigastric.
As you will find out if you spend some time talking to experienced emergency physicians, relief with a GI cocktail does not mean you're not having an MI. Same goes for pain that is reproducible with chest wall palpation. It points more towards a non-cardiac etiology of symptoms, but is by no means conclusive.

. I am not saying 7/10 chest pain can't be hypochondriasis, just that you can't dismiss a pt with that dx just after a CBC profile, chest CT/xray, and EKG. Just not good practice, IMO. I believe pain score is a vital sign in the VA Healthcare System and is also being used as one in many hospitals across the US. This is a debate for another thread :)
The Joint Commission claimed it was the fifth vital sign about a decade ago, and dinged hospitals that didn't record it, but I just wanted to point out that some patients are dramatic and some are stoic and pain score means less to me than what sort of medicine is required to control the pain. 10/10 pain that gets better with 1g PO Tylenol is less concerning than 6/10 pain that is still there after 5mg of IV Dilaudid.

Also, on second thought, another H. pylori test (both blood and breath) wouldn't hurt since the pt hasn't had one in over a year and a false negative is not out of the realm of possibility.
I'm not a gastroenterologist, but my understanding is that they usually want to have something other than vague dyspepsia (i.e. positive pH probe or EGD) before they test for H. Pylori -- you need to check with a specialist about that, though. Committing yourself to H. Pylori eradication therapy without good cause will probably result in more cases of C. Diff., anaphylactic reactions to antiobiotics, antibiotic resistance, and so forth. Cost is not the only consideration.
 

Droopy Snoopy

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I don't think this is medical advice, but you write too much like a physician to be a pre-pharmacy student so something doesn't jive. This was posted Sunday, it's Thursday. If it really is an assignment, and you really do have a boss, give him your/our best guess and give us the skinny. It's a nice case that deserves some resolution.
 

Tritleb

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Did anyone mention checking his TSH?