PATIENT: 46-year-old female; 5'6" (168 cm), 120 lbs (54.4 kg)
PRESENTATION: The patient presents with chest pain, dyspnea, and pain, tenderness, and a
sensation of heat in her right calf. The calf pain began 6 days ago, after she ran a marathon. The
dyspnea and chest pain began 1 hour ago.
MEDICAL HISTORY: She has a 6-year history of amenorrhea.
PSYCHOSOCIAL: She works for a bank. She was divorced 3 months ago and lives alone.
HEALTH HABITS: She is vegan. She usually runs 4 miles per day, 6 or 7 days per week;
however, when she is training for a marathon, she runs 10 miles on some days.
SUPPLEMENTS: She takes a daily multiple vitamin/mineral complex, and a botanical formula
containing Eleutherococcus senticosus.
MEDICATIONS: She has taken ethinyl-estradiol/mestranol daily for 6 years.
VITAL SIGNS: Her temperature is 99.1EF (37.3EC), BP is 128/78 mmHg, heart rate is 78 bpm,
and respiratory rate is 14/min and regular.
PHYSICAL EXAMINATION: On auscultation, her lungs are clear.
PRELIMINARY LAB RESULTS: Lab testing was not performed at this appointment.
DIAGNOSTIC IMAGING: Diagnostic imaging was not performed at this appointment.
1. What is the most appropriate first step?
A. Order Doppler studies.
B. Order pulmonary function testing.
C. Treat her symptoms with appropriate botanicals and physical therapies.
D. Immediately send her to the emergency department at the nearest hospital.
2. Given her presentation, what would you expect to find on physical examination?
A. absence of a pleural rub
B. a positive Homan's sign
C. an elevated ankle blood pressure
D. a negative Trendelenburg test
3. Which botanical medicine would most likely relieve her condition?
A. Crataegus oxycantha
B. Viburnum prunifolium
C. Gelsemium sempervirens
D. None of the above; botanical medicine would only mask her symptoms and would not
address the cause.
4. The most likely diagnosis is ________, but you must also consider ________.
A. pleurisy; deep vein thrombosis and intermittent claudication
B. intermittent claudication; pulmonary embolism and pleurisy
C. myocardial infarction; intermittent claudication and pleurisy
D. deep vein thrombosis; pulmonary embolism and myocardial infarction
5. If this is an adverse reaction, which of the following is the most likely causative agent?
A. oral contraceptives
B. her botanical formula
C. a topical analgesic she used to relieve muscle aches after she ran the marathon
D. an H2 blocker she took because she thought her SOB was due to an allergic reaction
6. After her condition has stabilized, which nutrient would be most indicated for her?
A. 5 mg of vitamin K, administered po
B. 300 mg of citrus bioflavonoids, administered po
C. 400 IU of topical vitamin E massaged into her calf
D. 100 mg vitamin B6 and 500 mg of magnesium, administered IV push
7. She is very loquacious and says the sensation of not being able to catch her breath is very
pronounced. She feels better while sitting up and bending forward. She had to loosen all her
clothes and is averse to having any clothing near her throat. Her leg is extremely painful and
she is angry that her friend who accompanied her is talking to you instead of fanning her to
help her breathe. Which homeopathic remedy best fits her picture?
A. causticum
B. lachesis muta
C. lycopodium clavatum
D. antimonium tartaricum
8. Which one of the following lifestyle changes would best help prevent recurrence?
A. engaging in deep breathing exercises
B. using a different form of birth control
C. adding animal protein back into her diet
D. engaging in a different form of exercise that is non-weight bearing
9. She hesitantly tells you that since her divorce she has begun smoking cigarettes. Which of the
following is the most critical component to ensuring long-term success in a smoking cessation
program?
A. the patient’s sense of self-efficacy
B. the patient’s social support network
C. the patient’s participation in a hypnosis program
Answers:
1. D 2. B 3. D 4. D 5. A 6. B 7. B 8. B 9. A
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