User:Thecheetahs/The Case Study: Diagnosing the Fatty (so not PC)

A 46-year-old woman, named Patty Lou-Lou McGee, presents with progressive dyspnea on exertion; at the age of 26 she was diagnosed with a heart murmur, but never sought therapy for it. At 46-years-old, Patty has a daughter and smokes a pack of cigarettes a day. We fear that if Patty's condition remains undiagnosed, she may end up with permanent physical damage, or worse, we fear that she may end up dead. Will we be able to help her?!?!

Physical Exam
Presentation:

•	46- year-old female c/o progressive dyspnea on exertion

•	relatively normal childhood

•	noted to have a heart murmur, didn’t seek therapy

•	had a successful pregnancy without hemodynamic compromise

Past History:

•	Chronic back pain

•	No diabetes mellitus

•	No hypertension

•	Effexor

•	Progesterone

•	Allergy to codeine and darvon

•	Hysterectomy

•	Lives in Louisiana with daughter

•	Smokes 1 pack a day

•	No alcohol

•	No IV drug abuse

•	No remarkable family history

Physical Exam:

•	Normal blood pressure

•	Normal heart rate

•	Normal resting rate

•	Overweight→ 231 lbs

•	Normal temperature

•	Alert and oriented

•	No acute disease

•	Head, ears, eyes, nose, throat within normal limits

•	Left carotid bruit: abnormal sounds usually due to fatty build up

•	No thyromegaly

•	No jugular venous distension

•	Normal S1 & S2

•	Grade 3 out of 4 systolic ejection murmur

•	Early ejection click: high pitched sound of aorta or pulmonary valves

•	Not radiating to the back

•	Click decreases in intensity during inhalation; no diastolic component

•	Abdomen= non tender, non distended, no H/S/M (??)

•	Lungs= clear to auscultation bilateral

Compilation of Symptoms
Patty's Symptoms:

-dyspnea

- early ejection click

- 2+ distal pulses

-heart murmur

-carotid bruit

-abnormal EKG

- left ventricular strain pattern on EKG

-prominent pulmonary artery shown on chest X-ray

-concentric left ventricular hypertrophy

-quite overweight

Diagnosis
We have diagnosed the patient with carotid stenosis. Stenosis is the narrowing of blood vessels and arteries.

Stenosis is frequently caused by excessive smoking (our patient smokes a pack a day), older age (46), and obesity (231 lbs)

The dyspnea, shortage of breath and constricted chest on exertion, initially lead us to believe that she had a respiratory problem such as emphysema, but after further examination, we realized that the problem was most likely a cardiac one due to the absence of clubbing in her extremities and lack of major damage to her lungs. We also recognized that the patient’s electrocardiogram showed abnormalities in the left side of her heart and this, coupled with her carotid bruit and heart murmur reinforced the possibility of a problem relating to her heart.

Carotid Artery stenosis, specifically, is the narrowing of the carotid artery in the neck which supplies blood to the head. If left untreated, carotid stenosis can result in a stroke.

Treatment
Based on our patient’s medical history, body type, and realistic time frame for recovery, we would begin treating her with antiplatelet drugs. Since the patient has a long history of excessive smoking, her heart, lungs, and blood vessels are very likely sensitive and fragile, hence our cautious entry into her treatment. Due to the Carotid Bruit that we heard, we are confident that the underlying cause of the Stenosis is the fatty buildup (atherosclerosis) in the patient’s carotid artery. To reduce this buildup, the least invasive step would be the drugs, which would hopefully clear up the blockage. These would reduce the platelet agglomeration around the patient’s clot and widen the vessel. If this initial treatment does not prove effective, our next step would be to perform a Carotid endarterectomy or an angioplasty. In the first procedure, we would open the artery and cut out the plaque causing the distress. In the latter, we would thread a catheter up from the groin, around the aortic arch, up the carotid artery, and would then inflate a balloon to expand the artery, and insert a stent to hold the artery open, allowing swifter and more normal blood flow through the artery.