Jacob Abraham iHuman Case Study

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Jacob Abraham i-Human Case Study Problem Statement

Jacob Abraham, a 58-year-old male, presents to the clinic with chest discomfort that began one week ago. The chest pain, located in the mid-sternal area, is described as burning and has woken him from sleep on four occasions, each lasting approximately 30 minutes or longer. The pain, rated at 4-5/10, occasionally radiates to his neck area around the Adam’s apple.

Jacob denies any history of similar chest pain or heartburn. His review of systems reveals no other significant symptoms, and his past medical history is non-contributory to his current presentation. The primary concern is to determine the etiology of Jacob’s chest pain, given its potential cardiac origin, necessitating a thorough diagnostic workup to rule out acute coronary syndrome (ACS) and other possible causes.

Reason for Encounter

Jacob Abraham, a 58-year-old male, presents to the clinic with complaints of chest discomfort.

History of Present Illness (HPI)

Jacob Abraham reports experiencing chest discomfort that began one week ago. The episodes of chest pain have been troubling, waking him up from sleep at night. The pain is located in the mid-sternal area and typically lasts for about 30 minutes or longer. So far, he has had four episodes of chest pain. Jacob describes the pain as burning and rates it at 4-5 on a scale of 10. He notes that occasionally the pain radiates up to his neck area around the Adam’s apple. Jacob denies any previous history of chest pain or heartburn.

Review of Systems (ROS)

• General: Jacob denies any weight loss, malaise, or night sweats. He is afebrile and provides a reliable account of his health history.
• HEENT/Neck: The pain sometimes radiates to his neck area around the Adam’s apple.
• Cardiovascular: Reports chest pain but denies heart palpitations, shortness of breath (SOB), or lightheadedness.
• Respiratory: Experiences chest pain but denies SOB or cough. There are no changes in his breathing pattern, although he takes shorter breaths when the pain is present.
• Gastrointestinal: Jacob consumes unhealthy meals, alcohol, and coffee.
• Genitourinary: No issues reported.
• Musculoskeletal/Osteopathic Structural Examination: No abnormalities noted.
• Neurologic: No neurological symptoms reported.
• Integumentary/Breast: No issues reported.
• Psychiatric: No psychiatric symptoms reported.

Discussion

The case of Jacob Abraham highlights several important considerations for clinicians evaluating a patient with chest discomfort. His presentation is concerning due to the nature and characteristics of the chest pain, particularly given that it wakes him from sleep and radiates to the neck. These symptoms warrant a thorough investigation to rule out potential cardiac causes.

Jacob Abraham iHuman Differential Diagnoses

1. Angina Pectoris:
   • Jacob’s chest pain characteristics and its mid-sternal location, combined with radiation to the neck, raise the possibility of angina pectoris. Angina typically presents with discomfort that can be described as burning or pressure-like and may radiate to the neck, jaw, or arms.
2. Gastroesophageal Reflux Disease (GERD):
   • Although Jacob denies a history of heartburn, GERD can present with chest pain that mimics cardiac pain. However, the lack of heartburn symptoms and the pain’s nocturnal onset make this less likely.
3. Musculoskeletal Pain:
   • While musculoskeletal pain can present with chest discomfort, Jacob’s description of the pain as burning and its radiation to the neck makes this diagnosis less probable.
4. Acute Coronary Syndrome (ACS):
   • Given Jacob’s age and the nature of his symptoms, ACS must be considered. This includes unstable angina or a possible myocardial infarction, necessitating immediate diagnostic workup.

Diagnostic Workup

To properly evaluate Jacob Abraham’s chest discomfort, the following diagnostic steps are recommended:

1. Electrocardiogram (ECG):
   • To assess for any ischemic changes or evidence of a past myocardial infarction.
2. Cardiac Enzymes:
   • Measurement of troponins and other cardiac biomarkers to rule out myocardial infarction.
3. Stress Testing:
   • To evaluate for inducible ischemia, especially if initial tests are inconclusive.
4. Echocardiography:
   • To assess cardiac function and rule out structural heart disease.
5. Chest X-Ray:
   • To rule out other causes of chest pain such as pulmonary or musculoskeletal conditions.
6. Laboratory Tests:
   • Complete blood count (CBC), lipid profile, and fasting glucose levels to assess overall cardiovascular risk.

Management Plan

Based on the findings from the initial evaluation and diagnostic tests, the following management plan should be considered:

1. Lifestyle Modifications:
   • Given Jacob’s consumption of unhealthy meals, alcohol, and coffee, dietary modifications, and lifestyle changes are essential.
2. Pharmacologic Therapy:
   • If a cardiac cause is confirmed, medications such as nitrates, beta-blockers, or antiplatelet agents may be initiated.
3. Referral to Cardiology:
   • For further evaluation and management if initial workup suggests significant coronary artery disease.
4. Patient Education:
   • Educating Jacob about recognizing symptoms and seeking immediate medical attention if his chest pain recurs or worsens.

Jacob Abraham iHuman Case Study

Jacob Abraham iHuman Case Study underscores the importance of a systematic approach to diagnosing and managing chest discomfort. By considering a broad differential diagnosis and utilizing appropriate diagnostic tools, healthcare professionals can provide comprehensive care and improve patient outcomes. For students and professionals seeking assistance with i-Human case studies, platforms like i-Human Case Study Answers offer invaluable support to enhance understanding and clinical skills.

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