Since Ms Smith has a history of anxiety, it is one of diagnoses being considered. An elevated blood pressure and increased heart rate would be in line with such a diagnosis, but her RR, temperature and oxygen level are not since they are all within the normal range. Anxious patients often have chest pain because their muscles are constricting and insufficient blood and oxygen is travelling through the veins. Ms Smith’s oxygen level is, at 99%, considered perfect, which means that blood and oxygen is flowing freely through her veins.
Gastro-Esophageal Reflux Disease (GERD) also warrants consideration, but only because it also can result in chest pain, a burning type of pain in the chest.
Coronary heart disease is also a consideration due to the chest pain. Angina can also be caused by a faster heart rate; and Ms Smith’s heart rate, although not tremendously high, is, nevertheless, 38 bpm above normal.
Panic attacks are another consideration. They also have chest pains and racing hearts.
Breathing difficulties also occur quite often; but, again, Ms Smith has a perfect oxygen level.
The questions I asked to obtain a full history of the present illness are:
When you get chest pain, how long does it last?
How often do you get chest pains?
What were you doing when the chest pains occurred?
What did you do when the chest pains occurred? Did it help?
Have you had an EKG, a stress test, and/or an angiogram? If so, when and what were the results?
Have you been diagnosed with high blood pressure, high cholesterol and high triglycerides? If so, are you on any medications for these?
How often, that you are aware of, does your heart beat faster than normal?
Do you have GERD or indigestion? If so, do you take any medications?
How has your weight changed over the last 20 years?
Are you anxious a lot of the time? If so, do you take medications for it?
Have you been experiencing panic attacks? If so, when and where? How long do they last? Do you take medications for them?
Ms. Smith’s physical exam showed a mildly hypertensive BP of 148/90, a pulse rate of 120 bpm and a shallow RR of 120. She seems tired and more anxious than a visit to an EMR normally engenders and is having trouble breathing. There is also a rash on her upper back.
Since she seems to be having hot flashes, I took her temperature and found it to be low-grade elevated 99 degrees Fahrenheit.
My diagnosis is Generalized Anxiety Disorder. I cannot, however, rule out the possibility of blocked arteries. As a result, I have admitted her for overnight for observations, some bloodwork, an EKG, and an angiogram.