Mrs. Payne is a 45-year-old woman who has not had preventive health care in five
years, presenting now for a routine exam. History reveals signs that she is
experiencing perimenopause, smokes one pack of cigarettes weekly, and has had
one abnormal Pap smear followed by a normal Pap smear since then. A complete
physical exam is performed with no remarkable findings, except that her BMI is 29
kg/m2, classifying her as overweight. Mrs. Payne is counseled regarding nutrition
and exercise to decrease her weight, osteoporosis prevention, and smoking
cessation. Preventative issues are also addressed when her immunizations are
brought up to date with a Tdap shot, a screening mammogram is scheduled, and
fasting glucose and lipid profiles are ordered.
Mrs. Payne's Pap smear results show evidence of Atypical Squamous Cells of
Undetermined Significance (ASC-US), which is explained at a follow-up visit and
repeat Pap is recommended in 12 months.
Mrs. Gomez is a 65-year-old Latina woman with
a past medical history significant for type 2 diabetes, hypertension, and
hypercholesterolemia. She presents today with six months of insomnia despite
self-medication with acetaminophen, diphenhydramine, and zapote blanco (a
Mexican herbal remedy). She also notes a lack of interest, inability to focus, and
decreased energy, but she denies suicidal ideation. She has been living with her
daughter and son-in-law since her husband died last year. Physical exam is
unremarkable with the exception of a ten-pound weight gain over the past year.
Diagnostic testing to exclude other medical conditions that could mimic depression
is ordered, and Mrs. Gomez is given citalopram.At a return visit two months later,
Mrs. Gomez admits that she never started the citalopram as she was worried that
people would think she was crazy. She also expresses concern that caregiving has
become too stressful for her daughter. These issues are addressed. At a final
return visit another two months later, Mrs. Gomez reports she is sleeping better
and taking an interest in things again.
medU | Instructors http://www.med-u.org/communities/instructors/fmcases/case_...
1. Instruct the patient to repeat
the following: "Apple, watch,
2. Administer the Clock- Drawing
Test (inside a circle draw the
hours of a clock as if a child
would draw them, then place the
hands of the clock to represent
the time "forty- five minutes past
3. Now ask the patient to repeat
the three items named
Sensitivity: 99% Sensitivity: 91%
If the three items are correctly
recalled, the screen is negative.
Mini-Mental State Examination
(MMSE)xamines orientation, memory,
and attention, as well as the
ability to name objects, follow
verbal and written commands,
write a sentence spontaneously,
and copy a complex shape.
Specificity: 93% Specificity: 92%
- Environmental problems: Noise or uncomfortable bedding
Counsel patients to avoid caffeine and alcohol for four to six hours
Ask about the use of prescription, over-the-counter, alternative, and
recreational drugs that might be affecting sleep
Sleep apnea: 20-70% of elderly patients. Obstruction of breathing results in frequent arousal that the patient is
typically not aware of
Bed partner or family member may report loud snoring or cessation of
breathing during sleep
Restless leg syndrome: Irresistible urge to move the legs, often
accompanied by uncomfortable sensations
Periodic leg movement and rapid eye movement (REM) sleep behavior
disorder: Involuntary leg movements while falling asleep and during
sleep, respectively. As in sleep apnea, the sleeper is often unaware of
these behaviors, and a bed partner or family member may need to be
asked about these movements
Disturbances in the sleep-wake cycle: Jet lag and shift work
Psychiatric disorders: Depression and anxiety
Asthma, chronic obstructive pulmonary disease, or congestive heart
Shortness of breath may keep patients awake.
Pain or pruritus may keep patients awake at night.
Gastroesophageal reflux disease (GERD): Heartburn, throat pain, or
breathing problems may awaken patients
Unusually long half-life (two to four days),
so effects can last for weeks after
Problematic side effects: agitation, motor
restlessness, decreased libido in women,
Fluoxetine and sertraline are the most
studied, and therefore most used, SSRIs in
pregnancy and breastfeeding.
Sertraline is approved specifically for
obsessive-compulsive, panic, and
posttraumatic stress disorders
Sertraline has more gastrointestinal side
effects than the other SSRIs.
Strong anti-anxiety effects
Best-studied SSRI in children
Side effects include significant weight gain,
impotence, sedation, and constipation
Due to short half-life, paroxetine is most
likely of all SSRIs to cause antidepressant
Particularly useful in obsessive-compulsive
Greater frequency of emesis compared to
Most common side effects include nausea,
dry mouth, and somnolence.
Approved specifically for generalized anxiety
Fewer side effects than citalopra
Sprain: The most common acute ankle injury is a lateral ankle inversion
sprain caused by a combination of plantarflexion and inversion. Because of
the bony articulation between the medial malleolus and the talus, medial
ankle sprains are less common than lateral sprains. In medial ankle sprains,
the mechanism of injury is excessive eversion and dorsiflexion. Medial ankle
stability is provided by the strong deltoid ligament, the anterior tibiofibular
ligament, and the bony mortise.
In general, ankle sprains present acutely (after trauma) with pain, warmth,
and swelling. Usually no gross deformity, although if there is a large amount
of swelling, there may appear to be a deformity. Symptoms generally
improve over time. After an ankle sprain, the joint may develop stiffness if
not exercised within the first few days.
Peroneal tendon tear: Usually due to an inversion injury or repetitive
trauma. May occur in conjunction with ankle sprain. Patient may complain of
persistent pain posterior to the lateral malleolus. Swelling may or may not
Talar dome fracture: May occur in conjunction with an ankle sprain, and
initial x-rays may miss a talar dome fracture. Repeat imaging may be required if symptoms persist to detect avascular necrosis. Overall prognosis
is related to potential for interruption of the blood supply.
Fibular fracture: Usually due to falls, athletic injury, or high velocity
mechanism, such as a motor vehicle accident. Patient may present with
severe pain, swelling, bruising, deformity, and inability to walk.
Tendonitis: Ankle tendonitis is an inflammatory condition, usually involving
the posterior tibialis tendon. Swelling/warmth may be present in the
affected area in addition to stiffness. Tendonitis tends to worsen initially
with aggravating activity only; it may then progress to discomfort at any
time. The pain of tendonitis is chronic, usually worse during the day and
Subtalar injury: Often due to a high-energy injury. A dislocation involves
the talocalcaneal and talonavicular joints. Pain, swelling, and deformity are
1. "RICE": Rest for the first 72 hours only, as not moving the ankle for a longer period
of time can cause more harm, such as decreased range of motion,
persistent pain and swelling, and chronic joint instability.
Ice several times throughout the day for ten minutes at a time reduces
swelling and may help with pain control.
Compression with tape, elastic wrap, or semi-rigid ankle support. (The latter
leads to quicker return to sports and work and less instability of the ankle.)
Elevation also helps to reduce swelling.
2. Anti-inflammatory medication
Associated with improvement in pain, function, and swelling. Instruct
patients (without contraindications) to take two or three ibuprofen (400 to
600 mg) at a time for pain, up to three times daily, as needed. Ibuprofen
should be taken with food.
3. Daily ankle exercises
Ankle inversion, ankle eversion, ankle plantarflexion, ankle dorsiflexion,
calf-stretching, and single-leg balancing. Proprioceptive exercises help
prevent and reduce the likelihood of re-injury.
4. Avoid potential re-injury
Avoid flip-flops or sandals and activities such as soccer until re-evaluation
(usually one week).
Ms. Waters is a 30-year-old woman who
presents with her partner to the clinic after several weeks of palpitations
associated with mild dyspnea, increased sweating, and some exercise intolerance.
She has also noticed weight loss, light periods, and loose stools. Exam reveals
tachycardia, lid lag, hyperreflexia of deep tendon reflexes, two beats of ankle
clonus, and fine tremor. After careful consideration of the differential diagnosis,
electrocardiogram (ECG), thyroid stimulating hormone (TSH), thyroxine (T4), and
complete blood count are obtained. The results confirm a diagnosis of
hyperthyroidism. The patient is given propranolol for adrenergic symptoms and
sent for a radioactive iodine uptake scan. Diffuse increased radioactive iodine
uptake despite low TSH confirms the diagnosis of Graves' disease. After being
educated about her treatment options, the patient chooses to take radioactive
iodine and is followed for several months until she returns with hypothyroid
symptoms, which are also treated.
Cardiac arrhythmias: Commonly cause palpitations, particularly when the
heartbeat is fast, though most people with arrhythmias do not notice
palpitations. Symptoms, when present, can be palpitations from rapid or
irregular heartbeat, lightheadedness, chest pain, and shortness of breath.
Some arrhythmias, like paroxysmal supraventricular tachycardia, are more
common in young people. Stress can cause arrhythmias due to adrenergic
Anxiety and panic disorder: Commonly cause palpitations and shortness
of breath. May be difficult to distinguish anxiety from hyperthyroidism, as
tachycardia, tremulousness, irritability, weakness, and fatigue are common
to both disorders. In anxiety, however, the peripheral manifestations of
excess thyroid hormones are absent; the skin is usually cold and clammy
rather than warm and moist. In anxious patients, weight loss usually occurs
due to anorexia as opposed to the increased appetite seen in
hyperthyroidism. Furthermore, panic attacks are distinct episodes of fear
and panic triggered by a particular place or event, or for no apparent
reason. A reasonable screening test for panic disorder is to ask, "Have you
experienced brief periods, for seconds or minutes, of an overwhelming panic
or terror that was accompanied by racing heartbeats, shortness of breath,
or dizziness?" Patients often underestimate how much stress they are under
and how much it can affect them. Especially in the setting of high stress,
palpitations are likely to be due to anxiety or panic disorder. In one
prospective study of 190 patients at a university medical center, 31% of
palpitations were due to anxiety or panic disorder.
Anemia: May cause palpitations because of tachycardia from hypovolemia.
The heart responds to low blood volume by speeding up to increase the
exposure of the blood to oxygenation in the lungs. Anemia can cause
dyspnea on exertion because of the lack of oxygen carrying capacity of the
blood. A common source of anemia in menstruating women is heavy
periods. It is unusual in young people to be losing blood from other sites
without obvious trauma. If the anemia is caused by a nutritional deficiency
(iron, vitamin B12 or folate), it may also be associated with weight loss.
Hyperthyroidism: Palpitations caused by tachycardia. The increase in
thyroid hormone increases the metabolism, including heart rate. In
hyperthyroidism, weight loss occurs despite increased appetite. Other
effects of hyperthyroidism are loose stools, hyperdefecation, light periods,
and sleep disturbance.
Drug/caffeine abuse: Most patients tell the truth about caffeine use,
though it is important to consider sources other than coffee and tea, such as many sodas. Street drugs, such as cocaine and even alcohol, can also cause
tachycardia. Caffeine and other drugs that cause palpitations (e.g.,
amphetamines, dextroamphetamines) can also cause weight loss. A high
index of suspicion should be maintained if someone has no other obvious
cause of palpitations and has other signs such as dilated pupils, increased
energy, increased blood pressure, and unusual behavior. Most people who
use cocaine would be unlikely to present to a physician office in this
Propranolol, a beta-blocker, can be used for symptomatic relief of adrenergic
symptoms (tachycardia, tremor, heat intolerance).
Patients diagnosed with Graves' disease should be referred to an
Medications: methimazole and propylthiouracil
Block thyroid gland from making more thyroid hormone
Side effects: Minimal, but low white blood cell count in < 1% of patients
Clinical improvement usually seen after one month, but three months before
thyroid level decreases
Treatment duration: Several years (> 50% of patients become hyperthyroid
when they cease medications)
Requires regular blood monitoring to keep dose optimal. Symptoms and
dose may fluctuate
May try this option initially and switch to radioactive iodine later.
Oral radioactive iodine (single dose):
Side effects: Transient (a few days) soreness of the neck or brief worsening
of symptoms. People with ophthalmopathy may experience worsening of
Over a few months the radioactive iodine destroys many of the overactive
thyroid cells, so that the level of thyroid hormone in the blood decreases.
Occasionally a second dose may be needed.
Eventually many patients become hypothyroid and need to take small doses
of replacement thyroid hormone.
Fewer European patients choose radioactive iodine compared to the U.S.,
where > 70% of patients choose this treatment.
Obtain pregnancy test prior to initiating radioactive iodine treatment. Also,
patient should not be near pregnant women or young children for several
days. Exposure of fetus or young child to radioactive iodine could result in
deleterious effect on their thyroid.
May be able to discontinue propranolol in a few months.
Check TSH every two to three months until it has stabilized and every six or
so months thereafter.
Expect patient to become hypothyroid at some point. Alert them to
symptoms of hypothyroidism in advance, so they can be tested earlier if
Not usually recommended as first-line therapy
If a test is administered to everyone, even those not really
at risk for a disease, the results lead to many false diagnoses. Screening,
however, helps to identify the population with a higher prevalence of disease.
American Diabetes Association (ADA) screening recommendations:
Overweight or obese (body mass index > 25 kg/m2) patients who have one
or more of the following additional risk factors:
Habitual physical inactivity
Race/ethnicity (e.g., Native American, Pacific Islander, Latin American,
African American, Asian American)
First-degree relative with diabetes
Previously diagnosed impaired fasting glucose (fasting glucose 100-125
mg/dL) or impaired glucose tolerance (2-hour plasma glucose 140-199
Hypertension (blood pressure > 140/90 mmHg)
High density lipoprotein cholesterol (HDL) < 35 mg/dL and/or triglycerides
> 250 mg/dL
History of gestational diabetes mellitus, or delivering a baby > 9 lbs.
Polycystic ovarian syndrome
History of cardiovascular disease
Other clinical conditions associated with insulin resistance (e.g., acanthosis
In the absence of the above risk factors, screening should begin at 45 years
If results are normal, testing should be repeated at least at three-year
intervals, with consideration of more frequent testing depending on risk
status and initial results.
Mr. Smith is a 53-year old obese male bus
driver with a history of type 2 diabetes, hypertension, hyperlipidemia, and
smoking who presents with a four-day history of left lower extremity swelling and
pain associated with erythema. On physical exam, Mr. Smith's entire left lower
extremity is tender, erythematous, warm, and swollen to 3.5 cm greater in
circumference than his right. His feet are dry, and his toenails are dystrophic and
incurvated, 3/10 sites are imperceptible using the 10-gram monofilament test,
and there is an ulceration present on the plantar surface of his left foot. The ulcer
is appropriately graded, and a differential diagnosis is generated. After carefully
considering the merits of obtaining a D-dimer test versus doppler ultrasound to
narrow the differential, a doppler ultrasound is ordered, and the results confirm
that Mr. Smith has a deep venous thrombosis (DVT) in his left greater saphenous
vein. Two anticoagulation options are considered. Mr. Smith's social situation is
taken into account while creating a treatment plan. He is admitted to the hospital
for anticoagulation, wound care, and coordination of appropriate care for his
chronic health issues. Transition to warfarin and dose titration are also addressed.
Single greatest contributor to mortality
During 2000-2004, approximately 443,000 people in the U.S. died
prematurely each year from cigarette smoking or exposure to
secondhand smoke (estimated annual average of 270,000 males and
Three leading specific causes of smoking-attributable death:
Ischemic heart disease
Chronic obstructive pulmonary disease (COPD)
An estimated 49,400 lung cancer and heart disease deaths annually
were attributable to exposure to secondhand smoke.
Smoking during pregnancy resulted in an estimated 776 infant deaths
annually during 2000-2004.
The average annual smoking-attributable mortality estimates also
include 736 deaths from residential fires caused by smoking.
Approximately 300,000 deaths annually
Rapidly gaining on smoking as the greatest cause of mortality in our
A body mass index (BMI) > 32 kg/m2 has been associated with a
doubled mortality rate among women over a 16-year period.
A BMI of 30-35 reduces life expectancy by two to four years
Severe obesity (BMI > 40) reduces life expectancy by 20 years for
men and 5 years for women.
213,062 deaths annually
Majority of deaths from diabetes result primarily from increase in
cardiovascular disease and chronic renal failure. (The risk of
cardiovascular disease in diabetics is so high that it is assumed that
they have cardiovascular disease if they have diabetes.)
Diabetics have twice the mortality risk of non-diabetics.
19,250 deaths annually
Uncontrolled hypertension decreases life expectancy by 20 years.
Most deaths are due to increased risk for coronary artery disease,
hypertensive cardiomyopathy, cerebrovascular disease, and chronic
Acute inflammatory condition of the skin characterized by
localized pain, erythema, swelling, and heat. Small breaks of skin are
associated with streptococcal infection, whereas staphylococcal cellulitis is
commonly associated with larger wounds, ulcers, or abscesses. This is likely
an acute, unilateral process.
Diabetics are more susceptible to infections like cellulitis. Diabetic
neuropathy results in insensitivity to abnormal pressure distribution,
ill-fitting shoes, and cuts or punctures which then develop ulcers. Vascular
disease with diminished blood supply contributes to the development of the
lesion, and infection is common.
The presence of a fever would support the diagnosis of an infectious process
like cellulitis. But lack of a fever does not rule out a diagnosis of cellulitis, as
it is possible to have localized cellulitis without fever.
Symptoms include acute swelling, pain, and discoloration in the affected
Physical examination may reveal the palpable cord of a thrombosed vein,
unilateral edema, warmth, and superficial venous dilation.
Patients with venous thrombosis often complain of a dull ache in the leg that
worsens with prolonged standing and resolves with leg elevation.
Classic signs of DVT, including Homan's sign (pain on passive dorsiflexion of
the foot), edema, tenderness, and warmth, are difficult to ignore, but they
are of low predictive value and can occur in other conditions such as
musculoskeletal injury, cellulitis, and venous insufficiency.
Smoking and obesity are the most robust risk factors in the development of
DVT and are independent of other risk factors. Diabetes, sedentary lifestyle,
hypertension, hyperlipidemia, increasing age, prolonged immobility, surgery, trauma, malignancy, pregnancy, estrogenic medications (e.g., oral
contraceptive pills, hormone therapy, tamoxifen [Nolvadex]), congestive
heart failure, hyperhomocystinemia, diseases that alter blood viscosity
(e.g., polycythemia, sickle cell disease, multiple myeloma), and inherited
thrombophilias are other potential risk factors for the development of DVT.
The presence of systemic
atherosclerosis in arteries distal to the arch of the aorta. As a result of the
atherosclerotic process, patients with PAD develop narrowing of these
Patients with PAD have a history of *claudication, which manifests as
cramp-like muscle pain occurring with exercise and subsiding rapidly with
Later in the course of the disease, patients may present with night pain,
non-healing ulcers, and skin color changes.
PAD can increase risk for a foot ulcer. An ankle-brachial index (ABI) can be
done to determine the presence of PAD. An ABI of <0.9 is consistent with
The greatest modifiable risk factor for the development and progression of
PAD is cigarette smoking. Cigarette smoking increases the odds for PAD by
1.4 for every ten cigarettes smoked per day.
Other risk factors for PAF include diabetes mellitus, hypertension,
hyperlipidemia, obesity, chronic renal insufficiency, elevated C-reactive protein levels, and hyperhomocysteinemia.
PAD is four times more prevalent in patients with diabetes than in those
without diabetes. Nearly half of patients who have had diabetes for 20 years
or more have PAD, usually below the knees.
1. Electrocardiogram: To assess rate and rhythm issues such as bradycardia,
tachycardia, or an underlying heart block. Beta blockers or calcium channel
blockers may be contraindicated for people with abnormal rates or rhythms. Look
for evidence of ischemic disease, previously undiagnosed myocardial infarctions,
or cardiac hypertrophy. Left ventricular hypertrophy (LVH) is the second best
prognostic factor for death in all people with or without hypertension. LVH is
reversible with proper attention and medical management.
2. Urinalysis: Proteinuria can indicate hypertensive nephropathy (target-organ
damage). Glucosuria may indicate undiagnosed diabetes or poorly controlled
diabetes (a potential co-morbid illness and sign of metabolic syndrome).
3. Blood glucose: An elevated random or fasting blood glucose may be evidence of
undiagnosed diabetes or poorly controlled diabetes (a potential co-morbid illness
and sign of metabolic syndrome). This may affect the choice of the first-line agent
used in managing hypertension.
4. Hematocrit: Low hematocrit may reveal anemic states in hypertensive patients.
Anemia makes the likelihood of a major cardiovascular event (e.g., stroke, heart
attack) more likely. If a hypertensive patient is found to be anemic, the
underlying cause (e.g., colon cancer or uterine fibroids) must be found and
addressed, and the anemia corrected. Anemia may also be the product of
target-organ damage in moderate to severe end-stage renal disease.
5. Serum potassium (K): Several blood pressure medications can cause potassium
derangements (angiotensin converting enzyme [ACE] inhibitors, angiotensin
receptor blockers [ARBs], and potassium- sparing diuretics, all of which may
cause or exacerbate hyperkalemia). A baseline potassium level is necessary for
determining any potential changes from antihypertensive therapy. Furthermore,
potassium disturbances can occur in Cushing's syndrome or primary
1. Serum creatinine or the corresponding estimated GFR: An elevated serum
creatinine (or the corresponding low estimated GFR) may indicate end- organ
damage (hypertensive nephropathy) from long-term uncontrolled hypertension.
Some blood pressure medications—such as ACE inhibitors, ARBs, and
diuretics—also elevate creatinine.
2. Fasting serum cholesterol panel (total cholesterol, LDL, HDL,
triglyceride): Obtained after a 9 to 12-hour fast, a lipid profile that includes
measurement of high-density lipoprotein (HDL), low-density lipoprotein (LDL),
and triglycerides is indicated to assess lipid co-morbidities. Hypertensive patients
have periodic fasting lipid panels as surveillance for cholesterol problems, and not as a general screening tool.
3. Urinary albumin excretion or albumin/creatinine ratio: The JNC 7 considers
the measurement of urinary albumin excretion or albumin/creatinine ratio (ACR)
optional, except for those with diabetes or kidney disease, in whom annual
measurements should be made. This may become a recommended test for all
hypertensive patients in the future JNC 8 report because microalbuminuria does
appear to have prognostic implications.
4.Serum calcium (Ca): JNC 7 also recommends serum calcium (Ca) level.
One-third of patients with hyperparathyroidism and hypertension may have illness
attributable to renal parenchymal damage due to nephrolithiasis. Increased
calcium levels can also have a direct vasoconstrictive effect. It is unclear why the
increased serum calcium level in hyperparathyroidism raises blood pressure, as
epidemiologic studies suggest that a high calcium intake lowers blood pressure. It
is also not clear why calcium channel blockers are effective antihypertensive
Heart Failure: Thiazides, beta blockers, ACE inhibitors, ARBs, aldosterone antagonists
Post-myocardial infarction: Beta blockers, ACE inhibitors, aldosterone
High coronary artery disease risk: High coronary artery disease risk
Diabetes: Thiazides, beta blockers, ACE inhibitors, ARBs, calcium channel blockers
CKD: ACE inhibitors, ARBs
Recurrent stroke prevention: Thiazides, ACE inhibitors
For Stage 1 hypertensive patients, initiate one medication—for most
patients a thiazide-type diuretic. (Other drug classes may also be
considered, such as an ACE inhibitor, ARB, beta blocker, or calcium channel
Stage 2 hypertensive patients without compelling indications are rarely
controlled on one drug alone. They usually require a thiazide-type diuretic
plus an ACE inhibitor, ARB, beta blocker, or calcium channel blocker. A
combination drug pill may reduce pill burden for patients and improve
Special caution must be exercised in initial combined therapy in those at risk
for orthostatic hypotension such as the elderly, diabetic patients, and
patients with autonomic dysfunction (e.g., paraplegic patients).
Ms. Yang is a 50-year-old female who
experienced palpitations, shortness of breath, and diaphoresis while exercising on
a treadmill. She gives a vague history of chest discomfort. Past medical history is
significant for hypothyroidism and gastroesophageal reflux disease. There are
multiple stressors in her life. Her physical exam is unremarkable except she
While evaluating these symptoms, the case reviews the classic and atypical signs
of ischemic heart pain, and contrasts the differences in presentation and outcome
of cardiac events in men vs. women. Students consider Ms. Yang's cardiac risk
factors, including family history of premature CHD, elevated cholesterol and
low-density lipoprotein (LDL), obesity, and sedentary lifestyle. Her 10-year risk of
cardiac event is calculated at low-intermediate. Electrocardiogram results are
normal, and several other laboratory tests rule out other etiologies of Ms. Yang's
palpitations considered on the differential.
Ms. Yang returns one week later to discuss results of her echocardiogram, which
ruled out structural abnormalities and exercise stress test, which showed no
abnormalities. She is educated about modifying her cardiac risk factors, given tips on exercise and nutrition, and counseled regarding stress relief.
The model used to identify symptoms of acute coronary syndrome (ACS)
has been consistently based on data primarily from men. The majority of
women with CHD present different from men.
95% of women report prodromal symptoms prior to myocardial infarction,
but only 29.7% report chest discomfort.
Atypical prodromal symptoms for ACS in women may include fatigue,
dyspnea, neck and jaw pain, palpitations, cough, nausea and vomiting,
indigestion, back pain, dizziness, or numbness.
Although CHD deaths in the U.S. have declined in men, the number of
coronary deaths in women has remained stable or increased.
The differences in presentation may be one reason for the disparities in
cardiovascular treatment and outcomes in women.
Women seem to be less aggressively treated than men and have worse
The fact that women are usually older at presentation than men and that
women tend to wait longer in seeking treatment may be part of the reason.
Also, women are less likely to participate in cardiac rehabilitation.
Unfortunately, one study showed that in ambulatory care setting, women
were less likely to be treated with a beta-blocker, aspirin, or a statin even
after having a heart attack. Effective strategies for diagnosing CHD earlier in
women is critical, as 40% of initial cardiac events in women are fatal.
Dysrhythmias: While these frequently cause palpitations, most patients
with dysrhythmias are unlikely to report having palpitations. Physical exam
and electrocardiogram do not rule dysrhythmias in or out. The patient may
have dysrhythmias that were not captured on the electrocardiogram. Loop
monitoring for two weeks would provide a greater chance of capturing the
Valvular heart disease (e.g., aortic insufficiency or stenosis, mitral valve
prolapse, atrial or ventricular septal defects, congenital heart disease,
cardiomyopathy, congestive heart failure, and pericarditis) can cause
palpitations. *Mitral valve prolapse is commonly associated with palpitations
and may be recognized on exam. It is classically a midsystolic click followed
by a crescendo-decrescendo murmur, usually best heard at the apex. It is
enhanced by Valsalva maneuvers and decreased by squatting.*
Coronary heart disease (CHD): An atypical presentation may include
palpitations. History suggesting cardiac etiology: the duration of palpitations
greater than five minutes, a description of an irregular beat (for example,
the patient can tap it out with their fingers), a previous history of heart
disease and male sex were more likely to predict a cardiac etiology. Also, a
history of palpitations affecting sleep or during work would increase the
likelihood that an arrhythmia was the cause of the palpitations.
Anxiety/panic attack: These are a frequent cause of palpitations,
especially in the setting of high stress. In a prospective study of 190
patients at a university medical center, 31% of palpitations were due to
anxiety or panic disorder (43% had palpitations due to cardiac causes, and
6% had palpitations due to prescription or recreational drugs).
Vasomotor symptoms of the climacteric (menopause) are a potential
cause of palpitations in menopausal women and are associated with heat
intolerance and sweating during a hot flash.
Choose an exercise you enjoy.
Exercise should be a combination of aerobic and strength training, ideally
with a component of flexibility.
Basic guidelines from the American College of Sports Medicine (ACSM) and
the American Heart Association (AHA) issued in 2007 for cardiovascular
Moderately intense cardio 30 minutes a day, five days a week, or
Vigorously intense cardio 20 minutes a day, three days a week, and
Eight to 10 strength-training exercises, 8-12 repetitions of each
exercise twice a week.
24-hour dietary recall is a quick nutritional tool. In this assessment, ask the
patient to recount what she ate while you ask clarifying questions regarding
spreads, condiments, beverages, and snacks.
Increased intake of plant proteins
Increased intake of omega-3-fatty acids
Decreased intake of saturated fats and trans-fatty acids, including oils
used in food preparation
Increased intake of dietary fiber and whole grains
Modify alcohol intake to none or moderate intake (1-2 standard drinks
Observe portion sizes.
Mr. Payne, a 45-year-old white male truck driver, presents with two weeks of
back pain and a tingling sensation down his left leg after lifting a 10-pound box.
Serious causes of lower back pain are excluded by history. Physical exam reveals
straight leg-raising (SLR) is positive at 75 degrees on the left. Mr. Payne is given
a provisionary diagnosis of back pain with radiculopathy and sent home for
conservative treatment with physical therapy. At follow up, three weeks later, Mr.
Payne's pain is now radiating down the lateral part of his left leg and the side of
his left foot. At this point, physical exam reveals positive SLR at 45 degrees on
the left, and reflexes are absent at the left ankle and 1+ at the right ankle. An
MRI is ordered, which depicts a large herniated disc at L5-S1. He is referred to
the pain clinic for consultation and possible selective S1 nerve root injections.
During a phone call two weeks later, Mr. Payne happily reports that the cortisone
injection was a big success. His pain is much improved and he has gone back to
work part-time. After a few months of improvement, Mr. Payne's pain flares up
again and he develops weakness of his left foot. A repeat MRI shows progression
of the disc herniation. He elects for surgery, which relieves his pain.
0/5 No movement
1/5 Barest flicker of movement of the muscle, though not
enough to move the structure to which it's attached.
2/5 Voluntary movement, which is not sufficient to overcome
the force of gravity. For example, the patient would be able to
slide their hand across a table but not lift it from the surface.
3/5 Voluntary movement capable of overcoming gravity, but not
any applied resistance. For example, the patient could raise
their hand off a table, but not if any additional resistance were
4/5 Voluntary movement capable of overcoming "some"
5/5 Normal strength
Range of motion
Hip Flexion (L 2, 3, 4): Ask the patient to lift his thigh while you
push down on his thigh
Hip Abduction (L 4, 5, S1): Ask the patient to push his legs
apart while you push them together
Hip Adduction (L 2, 3, 4): Ask the patient to push his legs
together while you push them apart
Knee Extension (L 2, 3, 4): Ask patient to extend his knee while
you push it down.
Knee Flexion (L 5, S1, S2): Ask the patient to flex his knee while
you push against it.
Ankle Dorsiflexion (L 4, 5): Ask the patient to point his foot up
while you push it down.
Ankle Plantar Flexion (S 1, S 2): Ask the patient to point his foot
down while you push it up.
Decreased strength implies nerve impingement of the associated
nerve in parenthesis.