Case Study: Chest pain

Presenting Complaint:

• Patient: Laura, a 52-year-old female, presented to the emergency department with sudden-onset chest pain that began 2 hours ago.

History of Presenting Complaint:

• Laura describes the chest pain as a severe, "crushing" sensation located in the center of her chest. The pain radiates to her left shoulder and jaw. She rates the pain as 9 out of 10 in intensity.

• The pain started suddenly while she was resting, and it has persisted without relief. She reports associated symptoms of sweating, nausea, and lightheadedness.

• She denies any recent physical exertion or emotional stress, and there is no history of trauma to the chest.

• She denies any prior episodes of similar chest pain but has experienced occasional mild chest discomfort in the past few months, which she attributed to indigestion.

• She has no significant cough, hemoptysis, or dyspnea, and no recent respiratory infections.

Past Medical History:

• Hypertension (diagnosed 8 years ago)

• Hyperlipidemia

• Type 2 Diabetes Mellitus (diagnosed 10 years ago)

• Gastroesophageal reflux disease (GERD)

• No known history of coronary artery disease

Medication History:

Allergies:

• No known drug allergies (NKDA).

Family History:

• Father died at age 68 from a myocardial infarction.

• Mother has a history of hypertension and stroke.

• No known family history of other cardiovascular diseases.

Social History:

• Laura is a non-smoker, does not drink alcohol, and lives a moderately active lifestyle.

• She works as an accountant and reports a high level of work-related stress.

• Diet consists mostly of processed foods, with minimal intake of fresh fruits and vegetables.

• No recent travel or exposure to unusual environmental conditions.

Systemic Review:

• Neurological: No recent headaches, dizziness, or focal neurological deficits.

• Cardiovascular: Severe, persistent chest pain, sweating, and nausea. No history of palpitations or known syncope.

• Respiratory: No cough, wheeze, or hemoptysis.

• Gastrointestinal: Occasional heartburn, well controlled with omeprazole. No recent changes in appetite, bowel habits, or weight.

• Genitourinary: No urinary symptoms.

• Musculoskeletal: No joint pain or swelling; no recent chest trauma.

Physical Examination:

• General: Anxious middle-aged woman, appears pale and diaphoretic.

• Vital Signs:

  • Temperature: 36.7°C

  • Blood Pressure: 145/90 mmHg

  • Heart Rate: 95 bpm, regular

  • Respiratory Rate: 22 breaths per minute

  • Oxygen Saturation: 93% on room air

• Cardiovascular:

  • Normal heart sounds (S1 and S2), no murmurs or gallops

  • Regular rhythm

  • No jugular venous distention (JVD)

  • No peripheral edema

• Respiratory:

  • Clear lung fields on auscultation

• Abdominal: Soft, non-tender, no organomegaly

• Musculoskeletal: Normal range of motion, no tenderness of the chest wall

Summary of Patient's Problems:

• Acute onset, severe chest pain with radiation to the shoulder and jaw

• Associated symptoms of sweating, nausea, and lightheadedness

• History of hypertension, hyperlipidemia, and type 2 diabetes

Questions:

1. What are the main differential diagnoses for this patient’s symptoms?

2. What initial investigations would you perform to confirm the diagnosis and identify any underlying causes?

3. What is your immediate management plan for this patient?

Differential Diagnosis:

Based on Laura’s clinical presentation and history, the primary differential diagnoses include:

1. Acute Coronary Syndrome (ACS):

   • The most likely diagnosis given the nature of the chest pain (crushing, central, radiating) and associated symptoms. Both unstable angina and myocardial infarction (STEMI or NSTEMI) should be considered.

2. Gastroesophageal Reflux Disease (GERD):

   • While GERD can cause chest discomfort, the severe and sudden nature of the pain, along with the associated symptoms (sweating, nausea), makes ACS more likely.

3. Pulmonary Embolism (PE):

   • Considered if the patient has risk factors such as recent immobilization or a history of deep vein thrombosis (DVT). However, the absence of hemoptysis, significant dyspnea, or pleuritic pain makes this less likely.

4. Aortic Dissection:

   • Severe, tearing chest pain radiating to the back would suggest this diagnosis. However, Laura’s pain is not described as tearing, and there is no evidence of unequal pulses or blood pressure discrepancies.

5. Musculoskeletal Pain:

   • Unlikely given the severity and quality of pain and lack of reproducible tenderness on physical examination.

6. Pneumothorax:

   • Would present with sudden, sharp chest pain and possibly dyspnea, but Laura’s pain is described as “crushing,” and her respiratory examination is unremarkable.

Initial Investigations:

1. Electrocardiography (ECG):

   • To assess for any signs of myocardial ischemia or infarction, such as ST-segment elevation or depression, T-wave inversion, or new-onset left bundle branch block.

2. Blood Tests:

   • Cardiac Enzymes (Troponins): To detect myocardial injury. Elevated levels indicate myocardial infarction.

   • Complete Blood Count (CBC): To check for anemia or signs of infection.

   • Urea and Electrolytes (U&E): To assess renal function, which is crucial for further management and medication dosing.

   • Coagulation Profile: To assess the risk of bleeding, especially if thrombolytic therapy is considered.

   • D-dimer: To rule out pulmonary embolism if clinically indicated.

3. Chest X-ray:

   • To evaluate for any other causes of chest pain, such as pneumonia, pneumothorax, or aortic dissection.

4. Echocardiogram:

   • To assess for left ventricular function, wall motion abnormalities, and any valvular heart disease if there is suspicion of heart failure or structural heart disease.

Management Plan:

1. Immediate Management:

   • Oxygen Therapy: If oxygen saturation is below 94%, administer supplemental oxygen to maintain adequate oxygenation.

   • Aspirin: Administer 300 mg of chewable aspirin immediately to inhibit platelet aggregation.

   • Nitrates: Sublingual nitroglycerin to relieve chest pain, provided there is no hypotension or contraindication.

   • Morphine: For pain relief if pain persists despite nitrates, titrate dose to response.

   • Anticoagulation: Consider anticoagulation with low-molecular-weight heparin (LMWH) or unfractionated heparin, depending on the diagnosis of ACS.

   • Dual Antiplatelet Therapy: If ACS is confirmed, add a second antiplatelet (e.g., Clopidogrel, Ticagrelor).

2. Further Management:

   • Beta-blockers: To reduce myocardial oxygen demand if not contraindicated (e.g., no bradycardia, hypotension, or heart block).

   • Statins: High-intensity statin therapy (e.g., Atorvastatin 80 mg) should be started or continued to reduce cholesterol and stabilize plaques.

   • Coronary Angiography: Urgent angiography is indicated if STEMI is confirmed, or consider if NSTEMI with high-risk features (e.g., hemodynamic instability, recurrent chest pain).

3. Long-Term Management:

   • Lifestyle Modifications: Advise on diet, exercise, weight management, and smoking cessation (if applicable).

   • Glycemic Control: Optimize diabetes management to reduce cardiovascular risk.

   • Blood Pressure Control: Tight control of hypertension with appropriate medications.

4. Follow-Up Plan:

   • Regular cardiology follow-up to monitor for recurrent symptoms, medication adherence, and adjustment of the treatment plan.

   • Consider cardiac rehabilitation to improve cardiovascular fitness and reduce recurrence risk.

Results of Investigations:

• ECG: ST-segment elevation in leads II, III, and aVF, consistent with inferior myocardial infarction.

• Troponins: Elevated at 6.5 ng/mL (normal <0.04 ng/mL), confirming myocardial infarction.

• Chest X-ray: Normal heart size, no evidence of pneumothorax, aortic dissection, or pneumonia.

• Echocardiogram: Mild left ventricular dysfunction with inferior wall motion abnormality.

Diagnosis:

• Acute ST-Elevation Myocardial Infarction (STEMI) involving the inferior wall.

Further Management Plan:

• Reperfusion Therapy: Immediate referral for primary percutaneous coronary intervention (PCI) if available within 90 minutes; if not, consider thrombolytic therapy.

• Continue Antiplatelet Therapy: Maintain dual antiplatelet therapy post-PCI.

• Long-Term Medications: Beta-blockers, ACE inhibitors (or ARBs), statins, and nitrates.

*All cases are fictional and any resemblance to real life is coincidental