Case Study

On Tuesday afternoon, a 52-year-old man with previously diagnosed coronary artery disease controlled by nitroglycerin describes episodes of recurring headache for the past 3 weeks. Mild nausea often accompanies the headache; there is no vomiting. He describes a dull frontal ache that is not relieved by aspirin. The patient states that the headaches are sometimes severe; at other times they are a nagging annoyance. The durations range from half an hour to a full day.

His visit was also prompted by a mild angina attack that he suffered this past weekend shortly after he awoke on Sunday morning. He has experienced no further cardiac symptoms since that episode.

History of previous illness indicates that the patient was diagnosed with angina pectoris 3 years ago. He has been taking 0.4 milligrams (mg) of sublingual nitroglycerin prophylactically before vigorous exercise. He also takes one aspirin every other day. He has been symptom-free for the past 2.5 years.

Sublingual nitroglycerin relieved the pain of the Sunday morning angina attack within several minutes.

The patient does not smoke and rarely drinks alcohol. He is a trim man with a slightly ruddy complexion.

At present, he is afebrile and his vital signs are

• Blood pressure 120/85,
• Pulse 80, and
• Respirations 20.

Physical exam is within normal limits.

The results of an electrocardiogram (ECG) with a rhythm strip performed in your office are unremarkable.

Subsequent laboratory testing reveals normal

• Blood lipids,
• Cardiac enzymes,
• Complete blood cell count (CBC),
• Sedimentation rate,
• Glucose,
• Creatinine, and
• Thyroid function.

Initial Check Questions

1. What would you include in the patient's problem list?
2. What would you include in the differential diagnosis?
3. What additional information would you seek to assist in the diagnosis?

Initial Check Answer(s)

1. The patient's problem list includes recurrent headache and nausea, and unstable angina pectoris.
2. The patient's differential diagnosis of chest pain includes myocardial infarction. The differential diagnosis of headache and nausea includes
   • Tension headaches,
   • Migraine,
   • Brain tumor,
   • Tooth or sinus problems,
   • Psychogenic headache,
   • Medication reaction (nitroglycerin can cause headaches),
   • Viral syndrome, and
   • Exposure to toxicants (carbon monoxide, solvents).
3. The additional information sought to make a diagnosis would include all aspects of a work and environmental exposure history.