Chapter 34 Chest and abdominal pain in the elderly

Case 34.1

A 70-year-old female presents with a 3-hour history of acute dyspnoea and right-sided chest pain. The pain is sharp in nature, and worse on inspiration. The symptoms commenced quite suddenly. She also states that she had a short episode of coughing, which was productive of a small amount of blood. She has never had these symptoms before.

One week ago, she was discharged from hospital following a hip replacement.

Apart from osteoarthritis in a number of joints (including the hip), she has been well. She has no history of respiratory or cardiovascular disease. She is a non-smoker.

Questions

1. What specific questions do you think it would be pertinent to ask?

2. What do you want to examine? What do you think you may find?

3. Do you need to refer this patient? Why?

4. Could the recent surgery be a possible precipitating factor? Why?

Case 34.2

A 79-year-old woman presents with a 1-day history of chest pain. She describes it as ‘burning’ in quality, on the lower right side of her chest, and radiating around to her back. There is no exacerbation with movement or breathing, but she has noticed that the movement of clothes over the skin seem to aggravate the pain. The skin is very sensitive to touch. She has never had any prior episodes.

Questions

1. What information does this description give you, regarding the source of the pain?

2. What do you suspect?

3. What do you wish to examine?

Your examination findings reveal hypersensitivity in the distribution shown in Figure 34.1.

Figure 34.1

Questions

4. What is your differential diagnosis?

5. How will you be able to distinguish between your differential diagnoses on clinical features alone?

6. Describe the aetiology of each disorder.

Case 34.3

A 70-year-old woman complains of bothersome chest discomfort of approximately 1 week duration. It is localised on the anterior chest wall, just to the left and right of the midline, at the level of the 2nd to 4th ribs. She cannot recall anything that may have precipitated it, nor has she been involved in any unusual activities. She denies any relationship of the pain to breathing, but there is a worsening of pain with movement. The symptoms have never occurred before.

Questions

1. What is your differential diagnosis, based only on this information?

2. What do you want to examine?

3. For each of your differential diagnoses, state what you would expect to find on physical examination.

4. What is the most likely diagnosis? Why?

5. Is this disorder usually bilateral?

6. What would you expect to see on a radiograph of this area?

7. How long would you expect the symptoms to last?

8. What are the major clinical differences between this disorder and costochondritis?

Case 34.4

Muriel is a 73-year-old woman who presents with a sudden onset of lower abdominal pain, localised mainly in the left iliac fossa. She states that it had been present for about 12 hours. Two hours ago, she passed some watery stools, which she believes had blood in them. Although she does occasionally have some diarrhoea, her usual problem is actually constipation.

Questions

1. What questions do you need to ask about the pain?

Muriel’s history reveals that the pain is constant, and made worse with any movement.

2. What is your differential diagnosis, based on this additional information?

3. What is meant by the term ‘colicky’ abdominal pain? Does this fit with her description of the pain? What information does the presence of colicky pain give you?

4. Based on the above information, name a maximum of three signs which would help to narrow your diagnosis.

5. Could her acute condition be related to her underlying constipation and occasional diarrhoea? Explain.

6. You refer Muriel to a medical practitioner for investigations. What abnormalities might be found in her full blood count?

Case 34.5

Mavis is an 80-year-old woman who complains of regular episodes of pain in the centre of her upper abdomen. She finds it hard to actually describe the sensation and says that it is not severe, but it is worrying her ‘in case it’s cancer’. She states that it occurs at least 3–4 times per week, generally 2–3 hours after a meal. There is no nausea, vomiting or changes in her bowel habits. She has not lost any weight. She is in good health apart from osteoarthritis, which is managed quite well with Naprosyn (naproxen).

Questions

1. What area of the abdomen is Mavis referring to?

2. What additional questions do you need to ask Mavis regarding her pain, in order to give a differential diagnosis?

3. Mavis states her pain commences 2–3 hours after eating, and taking antacids or drinking milk relieves the pain. What is the most likely diagnosis?

4. How would your diagnosis differ if the pain commenced while eating, or immediately after the meal?

5. Name the most important investigations that should now be done.

6. Briefly describe the pathogenesis of this disorder.

7. What are the possible complications? Which is the most common?

8. Is there any part of her history which may suggest a possible cause of her problem?

Case 34.6

History

Wendy is a 77-year-old patient sitting in your waiting room, who presents with a sudden onset of severe central chest and upper back pain. She does not lose consciousness, but complains of light-headedness and dyspnoea. Your receptionist informs you immediately of this incident.

Questions

1. What will you do now?

2. With no other information, what is the most likely diagnosis?

While waiting for help to arrive, you take a history from Wendy. She has consulted you in the past for low back pain associated with osteoarthritis, but has never experienced pain in her upper back or in her chest. She is unsure whether it actually started in her chest or back, but both occurred within seconds of each other.

You are aware of her medical history, which includes: osteoarthritis in her spine, hip and knee; type 2 diabetes mellitus, diagnosed at age 55; and a right-sided mastectomy for breast cancer 10 years ago.

Her last follow-up with the oncologist 12 months earlier revealed no recurrence of the tumour or metastases. Her diabetes requires insulin, but Wendy admits that she finds it difficult to maintain satisfactory levels of blood glucose. She has tried to lose weight, but has not succeeded. She did, however, stop smoking 12 months ago.

Questions

3. Does this information alter the probability of any of your differential diagnosis? Does it indicate the need for any additions to your list?

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