Medical Grand Rounds Clinical Vignette
James Tsay, M.D. March 5, 2008
Chief Complaint
32 year old, Caucasian woman, with history of asthma, GERD, and seasonal allergies presenting to primary care clinic for tobacco cessation.
History of Present Illness
Patient started smoking at the age of 18 and smoked 34 packs per day.
Initially wanted to quit 1 year ago because of cost of tobacco. After 4-5 months she was able to cut down to 10 cigarettes per day, however after a stressful event at work, she was back to 1-2 packs per day.
History of Present Illness
4 months prior to this visit, patient started on a nicotine transdermal patch.
After three weeks, she noticed that she had become anxious, irritable, and combative. At that time she switched over to a nicotine gum. While on the nicotine gum, she noticed her heartburn symptoms worsened and eventually stopped the gum.
Patient states she is very motivated to quit.
History
Past Medical History: Asthma, GERD, and seasonal allergies
Past Surgical History: none Medications: Albuterol MDI, Omeprazole Social History: Army officer from 1993-1995, social alcohol use, denied drug use, currently owns a marketing firm. Family History: Paternal grandparents were alcohol and drug abusers. Father, also was an alcohol/drug abuser, committed suicide when she was 2 years old.
Physical Exam
General: well-nourished Caucasian woman in no acute distress
VS: T 97.4' F, BP 108/56, P 68, RR 16, O2 sat 100% RA Chest: no crackles, wheezes, or rubs.
Exam was otherwise unremarkable.
Laboratory Values
Normal
Working Diagnosis
Tobacco addiction
Clinic Course
Patient did not wish to retry the nicotine transdermal patch at this time
Declined smoking cessation support group due to time contraints
Would like trial of Varenicline (Chantix).
Clinic Course
Patient returned 1 month later stating that Varenicline caused nausea and bad dreams. Stopped taking the medication few days prior.
Again patient declined support group. Patient was given a prescription for Bupropion to help with her cravings.
Follow up in one month.
Final Diagnosis
Tobacco addiction