FCM Sample Write-Up #4
Term 2, Winter Quarter
Sample B

ID/CC:

AB is a previously healthy 21 year old transgender woman presenting to UWMC with chest pain.

HPI:

Five days ago, approximately twelve hours after eating what she believes to be spoiled food, AB began experiencing diarrhea. A few hours later, after multiple episodes of mild abdominal pain, emesis and diarrhea she came to a local urgent care (ZoomCare) for her symptoms. Her symptoms of diarrhea and emesis lasted for two days and resolved on their own. The patient denies hematemesis, hematochezia, or fever.

Three days ago, the patient woke up and began experiencing chest pain. She describes the pain as a dull pressure located in the substernal region. At that time, the pain was non-radiating and mild in severity. The episode lasted for 30-45 minutes. The next morning (two days ago), the patient experienced another episode of similar chest pain lasting 30-45 minutes that prompted her to visit the the ZoomCare Urgent Care Clinic again. At the clinic, the patient underwent a laboratory work up before returning home.

One day ago, around 1:00 AM, while lying in bed, the patient began experiencing another episode of chest pain. This episode was far more severe than previous episodes. The patient describes the chest pain as an intense pressure located in the sternal region. The pain radiated superiorly towards her anterior cervical region. She had not experienced similar symptoms before. The patient attempted to alleviate her pain by changing positions, standing, sitting, and ambulating but reports no symptomatic relief. She also reports shortness of breath secondary to the pain. She notes having to take shallower breaths due to the severity of her pain. The pain worsened in severity until 3:00 AM when the patient was prompted to visit the ED for her symptoms. She denies LE edema, PND, orthopnea, nausea, emesis, diarrhea, or fever at that time. The chest pain was not associated with nausea or emesis.

Note: AB was assigned male at birth, and identifies as a transgender woman. She has not pursued gender-affirming treatments such as medical/hormonal treatment or surgical interventions for this in the past and is undecided about the future.

Hospital Course: While at the ED, the patient underwent X ray imaging, ECG, and a laboratory work up. Laboratory results showed an elevated Troponin I. The patient was medicated with ASA, Potassium, magnesium, and heparin and admitted for evaluation. She has since undergone a cardiac MRI, was diagnosed with acute myocarditis and pericarditis, and was started on anti-inflammatory medications. The patient reports one episode of chest pain since admission but states it was much milder in severity and did not radiate. She notes symptomatic relief and denies any current symptoms of chest pain or SOB.

PMHx:

None

Surgical Hx:

N/A

Current Medications:

None

Allergies: NKDA

Health Related Behaviors:

Sexual history: The patient is currently sexually active with female partners. Did not address contraception.

Tobacco use: The patient denies smoking tobacco or nicotine containing products including e-cigarettes, vape pens, or Juul pods.

Drug use: The patient denies recreational drug use including marijuana or any IVDU.

EtOH: The patient endorses drinking one bottle of wine per week

Diet/Exercise: The patient reports exercising regularly.

Family medical history:

The patient’s father has a hx of HLD no other family medical hx reported.

Social Hx:

The patient is currently a student at the University of Arizona studying computer science. She hopes to someday start her own company providing tech services for nonprofit organizations. She was born in Houston, and was assigned male at birth. Her family moved to the Seattle area when she was 10. AB began identifying as trans in her midteens and living as a woman since coming to college. AB uses she/her/hers pronouns. She feels well supported by her mother and brother, as well as a close community of friends on campus. She currently lives with three other roommates in Tucson (is in Seattle on spring break to visit family) and enjoys spending time with friends, hosting get togethers, working out and staying active.

ROS:

General: Negative for fevers or fatigue.

Skin: Negative for rash, pruritus, hair or skin changes.

HEENT: Negative for diplopia, discharge, vision changes, epistaxis, changes in hearing, otalgia, tinnitus.

Oral: Negative for dental pain, gingival bleeding, or hoarseness.

Pulmonary: Positive for SOB associated with chest pain. Negative for current SOB, wheezing, cough, nasal discharge, odynophagia, sputum production.

CV: Positive for chest pain. Negative for LE edema, PND, or orthopnea.

GI: Positive for nausea, emesis, diarrhea, diffuse abdominal pain (since resolved). Negative for constipation, dyspepsia, melena, hematochezia.

GU: Negative for dysuria, frequency, or hematuria.

MSK: Positive for mild lower back pain. Negative for arthralgias, myalgias.

Neurological: Negative for HA, focal numbness, unilateral weakness, tingling, syncope, or seizures.

Psychiatric: Positive for insomnia secondary to pain. Negative for anxiety.

Physical Exam

Vital signs: BP 116/72, RR: 10 bpm, Pulse: 74 bpm.

HEENT:

Head: Normocephalic, atraumatic, no scalp lesions.

Eyes: No conjunctival pallor or erythema. No scleral icterus. Pupils, equal, round, and reactive to light. Corneal light reflex intact bilaterally. Visual acuity 20/20 bilaterally. EOMI.

Ears: No mastoid or external ear tenderness to palpation. No visible discharge, patient responds to requests without hearing aids. Hearing intact to ringer rub. Bilateral TMs without erythema. Nose: External nose normal, septum midline.

Mouth: No oral lesions, no dental pain, TMJ without crepitus.

Throat/Neck: Mild anterior cervical lymphadenopathy. Thyroid without masses. 5/5 strength of bilateral sternocleidomastoid muscles.

Chest: Atraumatic. No tenderness to palpation. Symmetrical chest rise. Respirations unlabored. Symmetric respiratory excursions. Clear to auscultation bilaterally. Lung fields resonant to percussion bilaterally. No wheezing, no stridor.

CV: Regular rhythm. Normal S1 and S2, no S3, S4, or murmurs. No LE edema.

Abdomen: Tympanic to percussion, no tenderness to palpation, normal active bowel sounds.

Genital/Rectal not performed

MSK: ROM intact without pain in upper and lower extremities assessed at the elbows, wrists, knees, and ankles. No obvious asymmetry, atrophy, or swelling of joints.

Neurological: Alert and Oriented x3. Appropriate, cooperative. Sensation intact in upper and lower extremities bilaterally. 5/5 strength in bilateral upper and lower extremities, assessed at hands, wrists, and elbows. No pronator drift. Heel to shin intact, finger to nose without ataxia, gait ataxic, negative Romberg.

Summary:

AB is a 21 year old previously healthy transgender woman presenting to UWMC with multiple episodes of worsening chest pain x two days following three days of viral gastroenteritis. The patient reports midsternal chest pressure that radiates to the anterior neck. Her symptoms have since resolved. AB’s physical exam is otherwise unremarkable for abnormal heart sounds, murmurs, tenderness to palpation, rales, or asymmetric lung sounds.

Diagnosis Matrix

Assessment and Plan

 Given the patient’s lack of cardiac hx and history of present illness, the most likely diagnosis is acute pericarditis. The patient presented to the ED following complaints of diarrhea, nausea, emesis, and mild abdominal pain suggesting a viral gastroenteritis. After resolution of her GI symptoms, the patient began experiencing chest pain. The pain was described as a sternal pressure and worsened with inspiration. AB notes having to take shallow breaths secondary to the severity of the pain. There was however, no friction rub audible on cardiac exam. She did not have symptoms and signs suggestive of CHF which makes myocarditis less likely, though it can be associated with pericarditis and the elevated troponin suggests damage to the myocardium (more likely to represent myocarditis in this clinical scenario rather than acute MI 2/2 atherosclerotic disease).

An ECG of acute pericarditis often features diffuse ST elevations and PR depressions without Q waves or reciprocal ST depressions. Evaluating the EKG for signs of acute coronary syndrome would be important as well. According to the patient, the results of echocardiogram and cardiac MRI were also consistent with acute pericarditis and myocarditis.

Vasospastic angina was also considered as a diagnostic possibility. Given the patient’s age, lack of cardiac hx, and description of her most recent chest pain as a gradual onset pressure which radiated to her neck and was unchanged with position, vasospastic angina was considered. Risk factors for vasospastic angina include drug use such as cocaine, methamphetamines, magnesium deficiency and food borne botulism. The patient denies any hx of recreational drug or IVDU. While it is unlikely that the patient had food borne botulism, it is theoretically possible that she had a magnesium deficiency.

Finally, Pulmonary Embolism was considered. Chest pain associated with a PE is often described as pleuritic in nature. The patient describes her pain as a pressure, not sharp, burning or stabbing.

However, some patients are asymptomatic. Risk factors for a PE include smoking, DVT, estrogen therapy, recent surgeries, or inherited deficiency in the clotting cascade. The patient denies any past medical hx and does not have other risk factors. At this time, PE is considered less likely.