Case 35: Heartburn

Opening scenario

Janice Gardner, a 54-year-old female, comes to the physician because of heartburn.

Vital signs

• Temperature: 98°F (36.7°C)
• Blood pressure: 145/85 mm Hg
• Heart rate: 90/min
• Respirations: 20/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• You are worried and stressed out, and you want to get your refill and leave as soon as possible.
• When the examinee asks you about the location of your chest pain, point at the middle of your chest, between the nipples.
• You are not aware of the meanings of medical terms (e.g., ECG), and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: When the examinee recommends that you stay longer for some tests, say: “Is all this really necessary? I need to get back home to my mother. She is all by herself, and someone needs to look after her. Can you not just give me my refill?”

Hovering over the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form will not interrupt your progress.

History of present illness

• Chief complaint
• I have been having some heartburn and want to get my prescription refilled.
• Location
• When I have it, it hurts in my chest right behind the bone here in the middle.
• Intensity (on a scale from 0–10)
• It depends when. When it gets really bad, it is almost an 8 or 9. Other times it has been around a 1–2, but it can also completely disappear sometimes too.
• Quality
• It is a little bit of a burning pain and a kind of a pressure, like somebody is standing on my chest.
• Onset
• I have had heartburn for about 10 years now, but it has been worse for the past 3 weeks.
• Precipitating events
• I ran out of my heartburn medication 3 weeks ago.
• Progression/constant/intermittent
• I have it a few times every day. It got worse when my medication ran out. And I feel like the past 2 days have been really bad. It used to be only at night, but now I get it during the day as well.
• Previous episodes
• No. I have never run out of my medication before.
• Radiation
• Yes, to my stomach.
• Alleviating factors
• It gets better when I rest.
• Aggravating factors
• It gets worse when I am stressed out or when I have to move around a lot. Earlier today I forgot my wallet at the grocery store and had to run back in. That is when it got really bad! I even had to stop for a minute to rest.
• Associated symptoms
• None. Just the heartburn.

Review of systems specific to chest pain

• Swelling of the ankles
• No.
• Nausea/vomiting
• Yes, when the heartburn gets really bad, I also get a little bit nauseous.
• Fatigue
• I am always tired. But for the past few weeks I have felt like I just could not move around as much as I used to. It just makes the heartburn worse. And I feel like I am always getting heartburn now.
• Racing of the heart
• Yes, my heart does race pretty often, especially when I am stressed out or the heartburn is really bad.
• Cough
• No.
• Shortness of breath
• Earlier today when I ran in back to the grocery store, I felt really short of breath. But that was the first time.
• Sleep problems
• I never sleep well. I am always worried about my mother.
• Recent infections
• None.
• Dizziness
• Sometimes when my heart is really racing fast I also feel dizzy.
• Anxiety
• Sometimes when I realize that I am the only person who can take care of my mom, I get really anxious and my heart starts beating really fast.
• Depression
• No. I am stressed out, and I could really use a break, but I am not depressed.
• Sweating
• Yes, when my heart is racing I also start sweating a lot.

Past medical history, family history, and social history

• Past medical history
• I have hypertension and heartburn.
• Allergies
• None.
• Medications
• I take hydrochlorothiazide and omeprazole.
• Hospitalizations
• Never.
• Past surgical history
• None.
• Family history
• My dad died of a heart attack when he was 60 years old. My mother has dementia, so I take care of her.
• Work
• I work as a secretary.
• Home
• My kids are in college and I am divorced, so 2 years ago I moved in with my mother to take care of her. During the day I try to do as much work as I can from home so that she is not alone.
• Alcohol
• Sometimes I have a glass of whiskey on the weekends, but that is it.
• Recreational drugs
• Never.
• Tobacco
• I have smoked 2 packs of cigarettes daily for the past 40 years.
• Exercise
• I wish! I do not really have time to exercise.
• Diet
• I know I should eat better, but with work plus my mom I just do not have time to cook. We eat a lot of frozen dinners.

• Washed hands
• Used respectful draping
• Neck exam
  • Evaluation of JVD
  • Auscultation of the carotid arteries
• Cardiovascular exam
  • Inspection of the chest
  • Palpation of the chest
  • Palpation of the apical impulse
  • Palpation of the radial pulse
  • Auscultation of the heart
• Chest exam
  • Auscultation of the lungs
• Abdominal exam
  • Auscultation of the abdomen
  • Palpation of the abdomen
• Extremities
  • Inspection of the hands
  • Examination for pitting edema
  • Palpation of pedal pulses

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on smoking cessation.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: ”Ms. Gardner, I understand that you would like to get back to your mother. At the same time, I am concerned that the symptoms you are describing might not actually be the result of your heartburn but rather a narrowing of the arteries of your heart. I would highly recommend that you stay here, so we can run some tests to diagnose you properly, and treat you if necessary. I can make sure one of our social workers comes to see how we can take care of your mother while you get some tests. At some point, I would also like us to work out together whether you might need more help taking care of your mother in the long run. It sounds like the stress of working and taking care of her may be negatively affecting your health, and as your doctor I want you to be as healthy as you can be.”

Patient note

Differentials diagnoses

1. Angina pectoris: This patient has multiple risk factors for coronary artery disease and angina pectoris, including a history of smoking and hypertension, and a high level of daily stress. Retrosternal, pressure-like pain triggered by exertion or stress is the cardinal symptom of angina pectoris, the most likely differential in this case. The pain may radiate to the epigastrium and be accompanied by dyspnea and vegetative symptoms such as diaphoresis, palpitations, dizziness, and nausea. New-onset angina always requires a workup; it is essential this patient not simply be sent home with her medication refill.
2. Gastroesophageal reflux disease: This patient has a 10-year history of poorly controlled gastroesophageal reflux disease with continuing symptoms. She has several risk factors for the condition, including smoking and stress. Retrosternal burning pain or pressure and nausea are common symptoms of acid reflux, especially if they occur following meals and when lying supine or bending down. However, this patient's symptoms appear to be triggered by stress and, most concerningly, exertion.
3. Generalized anxiety disorder: Patients with generalized anxiety disorder have prolonged, excessive anxiety not caused by any substances, medications, or other medical conditions. They may suffer from poor sleep, which this patient has, as well as panic attacks precipitated by escalation of their anxiety, among other symptoms. This patient's chest pain, dyspnea, diaphoresis, palpitations, dizziness, and nausea could all be caused by periodic panic attacks.

Cardiac causes of chest pain should always be excluded first, even in patients with assumed GERD!

Diagnostic studies

• ECG: best initial test for suspected cardiac ischemia
• Cardiac stress test: Cardiac stress tests are generally most useful in patients with an intermediate pretest probability of coronary artery disease.
• CK, CK-MB, troponin: important laboratory markers of myocardial infarction; negative in angina pectoris
• Transthoracic echocardiography: can detect abnormalities in cardiac wall motion in cardiac ischemia and infarction
• Coronary angiography: gold standard for CAD diagnosis; should be conducted if non-invasive procedures yield pathological or ambiguous results

Other differential diagnoses to consider

• Costochondritis
• Panic disorder
• Cardiac arrhythmia
• Congestive heart failure
• See also differential diagnoses of acute chest pain.