Chapter 34 Chest and abdominal pain in the elderly
Case 34.1
1. What specific questions do you think it would pertinent to ask?
A full history should be taken. Specifically:
• Enquire about any symptoms which could indicate the presence of a deep vein thrombus (eg: swelling of one limb, asymmetrical temperature between right and left limbs, or pain in the limb).
• How long was she in hospital for? How quickly did she start moving around following the operation?
2. What do you want to examine? What do you think that you may find?
Specifically, the following need to be performed:
• vitals: tachypnoea usually occurs with pulmonary infarction, and a slight pyrexia may occur with a deep vein thrombosis
3. Do you need to refer this patient? Why?
It is often necessary to perform a number of tests to diagnose this condition. For more details on investigating this disorder, refer to Sutherland.[1]
Case 34.2
1. What information does this description give you, regarding the source of the pain?
It suggests that the pain is neurogenic in character, and possibly dermatomal in distribution.
5. How will you be able to distinguish between your differential diagnosis on clinical features alone?
• Shingles usually involves the appearance of skin lesions (papular and then vesicular) in the area of pain, 2–3 days after the commencement of the pain.
• Pleurodynia is often preceded by upper respiratory tract symptoms, and may also be accompanied by headaches, fever and malaise, and possibly gastrointestinal symptoms (eg: pain, nausea, vomiting and diarrhoea).
6. Describe the aetiology of each disorder.
• Shingles — is the result of re-activation of the herpes zoster virus.
The virus lies dormant in the dorsal root ganglia of peripheral nerves, following an earlier exposure to the virus. This would have presented at the time as either ‘chicken pox’, or as a ‘sub-clinical’ infection with no overt clinical manifestations. The exposure may have been many years earlier.
The virus lies dormant in the dorsal root ganglia of peripheral nerves, following an earlier exposure to the virus. This would have presented at the time as either ‘chicken pox’, or as a ‘sub-clinical’ infection with no overt clinical manifestations. The exposure may have been many years earlier.
Case 34.3
3. For each of your differential diagnoses, state what you would expect to find on physical examination.
| Differential diagnosis | Expected findings on physical examination |
|---|---|
| DDx 1: costochondritis | Tenderness over costochondral junctions in area of pain |
| DDx 2: Tietze’s syndrome | Tenderness over costochondral junctions in area of pain plus swelling over joints |
| DDx 3: myositis (muscle strain) | Tenderness in intercostal spaces |
Case 34.4
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?
Colicky pain refers to pain which varies in intensity. There is either:
Muriel’s description is not that of colic.
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.
Case 34.5
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?
6. Briefly describe the pathogenesis of this disorder.
For details of the pathogenesis of this condition, please refer to Thompson and Leung.[2]
Case 34.6
1. What will you do now?
Assess the patient for vital functions, and ask the receptionist to call an ambulance.
3. Does this information alter the likelihood of your diagnosis? Does it indicate the need for any additions to your list?
