PRESENTATION: The patient presents with heartburn and chest pain. She describes a heavy
and squeezing pain, and says it is better when she rests. She denies shortness of breath but says
that sometimes when the pain is at its worst, she notices that she perspires slightly. She thinks she
may have food poisoning because she ate in a restaurant 2 nights ago, and has not felt well since
that time. The symptoms have been intermittent during the past 3 days.
MEDICAL HISTORY: Her last office appointment was 5 years ago to address menopausal
symptoms. At that time, her BP was 142/92 mmHg. She chose to address her borderline
hypertension with lifestyle modifications. She says that due to her busy schedule, she has not had
time to follow-up with you.
PSYCHOSOCIAL: She is a landscape architect and says that for the past 5 days, she has been
doing relatively strenuous work.
HEALTH HABITS: She eats an omnivorous diet, and emphasizes that the fresh food she buys is
usually organically grown. Because her work is physically challenging, she does not follow a
regular exercise regime. She does not drink alcoholic beverages or smoke.
SUPPLEMENTS: She takes a daily multi-vitamin and extra calcium.
MEDICATIONS: none
ALLERGIES: none known
FAMILY HISTORY: Her father died of a myocardial infarction at age 60 and her mother has
hypertension.
VITAL SIGNS: Her BP is 162/90 mmHg, heart rate is 84 bpm, and respiratory rate is 16/min.
PHYSICAL EXAMINATION: Neurological examination is unremarkable. There is no evidence
of peripheral edema. On auscultation, her lungs are clear, but you hear S1/S2 with occasional
premature beats, and a soft S4 is heard over the apex.
PRELIMINARY LAB RESULTS:
TEST US VALUE US RANGE CANADIAN VALUE CANADIAN RANGE
total cholesterol 250 mg/dL < 200 mg/dL 6 mmol/L < 5.1 mmol/L
LDL 165 mg/dL < 100 mg/dL 4.1 mmol/L < 2.6 mmol/L
HDL 30 mg/dL > 35 mg/dL 0.85 mmol/L > 0.9 mmol/L
DIAGNOSTIC IMAGING: Diagnostic imaging was not performed at this appointment.
1. The most likely diagnosis is _______ but you must also consider ________in your
differential.
A. pleurisy; costochondritis and GERD
B. pleurisy; esophageal spasm and costochondritis
C. ischemic heart disease; GERD and costochondritis
D. ischemic heart disease; esophageal spasm and pleurisy
2. Your first step would be to order a(n) ________ to rule out ________.
A. echocardiogram; pleurisy
B. ECG; ischemic heart disease
C. CPK with MB bands; pleurisy
D. chest radiograph; ischemic heart disease
OR, A DIFFERENT FORMAT TO TEST THIS COMPETENCY WOULD BE:
3. If an ECG showed _______ , it would indicate ________.
A. premature beats; myocardial ischemia
B. wide QRS complex; a 2nd degree block
C. prolonged PR interval; a 3rd degree block
D. elevated ST segments; myocardial ischemia
4. Which one of the following drugs is most indicated for her condition?
A. aspirin
B. atropine
C. acetaminophen
D. hydrochlorothiazide
5. She says the symptoms generally occur after exertion, but sometimes she is awakened at 1:00
a.m. by the pain, which is relieved if she drinks a hot beverage. Which one of the following
homeopathic preparations best addresses her presentation?
A. phosphorus
B. arnica montana
C. arsenicum album
D. aconitum napellus
Answers:
1. C 2. B 3. D 4. A 5. C
Arsenicum album
Keynotes: Anxiety, Restlessness, Aggravated by cold, Worse 1-2pm and 1-2am, Thirsty for sips, Periodicity, Alternating of Symptoms, Ulcerations, Burning PAINS.
M/E: INSECURITY. Sense of being vulnerable and defenceless in a seemingly hostile universe. DEPENDENCY on other people. Needs people NEARBY. POSSESSIVE of objects, money and people. ANXIETY ABOUT HEALTH. Fear she will die. (Phos will have great anxiety about health too, but will plead for help, where Ars will demand help). Fear of being alone.
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