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Student Case #6


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Initial thoughts that come to mind:

1) What is her past medical history? MI? PE? spontaneous pneumo? smoker? rheumatic heart disease? pericarditis? Recent illness?

2) What medications is she taking?

3) The nature of her pain? Location? timing? pleuritic or generalized? Positions that make it worse/improvement?

4) Recent travel? Taking Estorgens? Is she experiencing SOB or only chest pain? She is stating at 100% which is good.

5) What does he chest x-ray look like? That could provide some valuable information.

6) How does she appear? sick vs. not sick? cyanotic, cap refill, distal pulses, etc. How did the heart and lungs sound? Calf pain/swelling?

7) Basic labs: serial cardiac enzymes, CBC with dif, CMP, could do a d-dimer but wouldn't give much clinical info if you are suspecting a PE based on her presentation.

 

My EKG interpretation could use some improvement... I dont see a heart block of BBB. Possible LVH. No ST elevation or Q waves.

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Let's start with the history before physical exam and labs... all good thoughts though. She looks uncomfortable but not sick.

 

HPI:

The nature of her pain? Location? timing? pleuritic or generalized? Positions that make it worse/improvement?
Patient described a "sharp, burning" substernal chest pain that radiates up her throat and to her back. Began 2 days ago while she was mowing the lawn and has been present ever since. Vascillates between 4-8/10. Worse when lying flat and deep inspirations. Feels slightly better when sitting up, but still uncomfortable. Waited to come in because she thought it would just go away on its own
Recent travel? Taking Estorgens? Is she experiencing SOB or only chest pain? Recent illness?
Denies shortness of breath. No recent travel and is not on HRT. Season allergies with rhinorrhea more active over the past several weeks but denies illness.

 

PMHx:

Osteoporosis

Moderate GERD

 

Medications:

Fosamax 70 mg qTuesday

Omeprazole 40 mg qd

 

SHx:

Quit smoking 25 years ago.

 

What else?

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Sounds and looks like classic Pericarditis to me (worse when laying flat, radiates to her back, peaked T-waves could suggest hyperkalemia)...but I'm just a medic who's starting PA school in August. Would love to know the outcome. :)

 

In addition- What do her baseline electrolytes look like? Could be a simple ERS without any actual underlying cardiac issue...and strictly muscular from the lawn-mowing.

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Interesting case, i'm a novice but let me try to contribute. A good H&P will normally leads to the right diagnosis, and i agree with acozadd list of questionaires. The presentation of pain that is worse when lying flat and improves when sitting up does lend credibility to possible pericarditis. If so, NSAIDS will alleviate her condition. Her temp is normal though.

 

From the look of her EKG, there's Q waves in inferior leads (II, III, aVF) which may signify prior infarct. I would like to compare her EKG with prior ones. There's significant Q waves and hyperacute T-waves in the anterioseptal leads (V1,V2,V3,V4) and poor R-wave progression noted. No evidence of LBBB or LVH that could signify pseudoinfarct so the hyperacute peaked Twaves are more concerning for anteriorseptal MI or hyperkalemia. With a history of GERD, this chest pain may be secondary to it. Still, i am concern of the Q waves so i do want to see prior EKG. Meanwhile, PPI administration for prophylaxic.

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How well is her GERD controlled? How has it progressed, how compliant to the PPI has she been, has she ever been scoped?

Excellent thought. GERD poorly controlled even on omperazole 40 daily, which she has been compliant with. Has never had an endoscopy... scheduled for one in about a month.

 

If these symptoms are due to GERD, what could be making them worse?

 

From the look of her EKG, there's Q waves in inferior leads (II, III, aVF) which may signify prior infarct.

What's considered a pathologic Q wave? With a first set of negative enzymes in setting of 2 days of chest pain, unlikely that this is NSTEMI.... but could be unstable angina? What questions should we be asking?

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Excellent thought. GERD poorly controlled even on omperazole 40 daily, which she has been compliant with. Has never had an endoscopy... scheduled for one in about a month.

 

If these symptoms are due to GERD, what could be making them worse?

 

 

 

GERD that is refractory to PPI could be due to an abnormality of the LES, possibly a hiatal hernia. She could have incarceration of the proximal stomach leading to the acute symptoms, she could have an esophageal perforation, it could be zollinger ellison depending on how long this has been going on. With the high O2 stats, and lack of any real cardiac findings (we haven't heard what that heart sounds/lung sounds are) then GI seems like a likely target, especially given her history.

 

How great of a depression is needed for something to be considered a Q wave? THose seem pretty minor to me, but like I said I dont have that much experience with EKGs. Same question applies for the peaked T-waves. If her EKG has pathologic findings then it could change my approach.

 

CXR would still be very valuable... you could assess the heart, lungs, vasculature (look for thoracic aortic aneurysm), etc. If bowel is present above the level of the diaphragm that could be useful as well.

 

Worsening symptoms in the supine position could just as well be GI related as it could be cardiac. You could give the GI cocktail and see if there is improvement of symptoms, with her history it couldn't hurt.

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Ahh, good point. I was interpreting that the Q waves to be pathological in the inferior leads to be 2mm deep, but looking back at it the depth may be <2mm. as far as unstable angina, i would ask for the duration of pain. If it's stable, then the correlation with exertion.

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i would ask for the duration of pain. If it's stable, then the correlation with exertion.

No prior history of chest pain other than esophageal burning when lying flat and with acidic foods which prompted prescription of omeprazole and EGD scheduling. Bicycles several times per week (~6 METS). No orthopnea or PND.

FHx:

No history of CAD or SCD.

 

I was interpreting that the Q waves to be pathological in the inferior leads to be 2mm deep, but looking back at it the depth may be <2mm.

Great.. so it's usually 0.04 wide (1 small) by 0.08 (2 small boxes) deep. It's hard to really see on this EKG, but I tried to find one that best resembled this patient's initial. Let's assume there are no pathologic q waves. What I read on her 1st EKG was ST at 100. Nl axis. ?PR depression in II. Borderline LVH with repolarization abnormality.

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To fill out the "S", beyond what's been asked already, so we can get on to PE, labs, etc.... (see, I do learn that there's an order to this...)

 

* Surgical Hx?

* EtOH? What was total pack/years on her smoking (and always positively reinforce her having already quit!)

* Social Hx?

* Family Hx, focusing on GI, pulm, cardiac.

* Does pain correlate with her Fosamax? (My DDx included duodenal ulcer before I noted that it, along with esophageal erosions, are known serious side effects of the Fosamax)

* ROS: General (F/C/N/V, weight loss/gain, night sweats), GI, Cardiac, Pulm.

 

And I think that should mostly wrap up history, unless we're overlooking something brought up in one of the other answers.

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To fill out the "S", beyond what's been asked already, so we can get on to PE, labs, etc.... (see, I do learn that there's an order to this...)
Haha. I love it.
* Surgical Hx?
None.
* EtOH? What was total pack/years on her smoking (and always positively reinforce her having already quit!)
Drinks a glass of red-wine about once a week. Quit smoking as above about 25 years ago with 20 pack-year history.
* Social Hx?
Single. Works as a teacher. No IVDU.
* Family Hx, focusing on GI, pulm, cardiac.
None. One of the rare patients with healthy family.
* Does pain correlate with her Fosamax? (My DDx included duodenal ulcer before I noted that it, along with esophageal erosions, are known serious side effects of the Fosamax)
You're on it rev ronin. Esophageal burning worse since starting fosamax 6 months ago. Food increases the pain. However, current symptoms are significantly increased from baseline, and radiation to the back is new.
* ROS: General (F/C/N/V, weight loss/gain, night sweats), GI, Cardiac, Pulm.
+rhinorrhea with some green discharge. No fevers, chills, cough, weight gain/loss etc.

 

With chest pain that radiates to the back, what should we be checking on physical exam?

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Hmm... Radiation to the back combined with rebound tenderness would be consistent with perforated ulcer. Of course, with any pain that radiates to the back, I want to rule out AAA as well. I have this nagging feeling I'm forgetting something else simple, but unfortunately, I need to hit the road to get back to my rotation site tonight, so will read with interest how this resolved tomorrow...

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Hmm... Radiation to the back combined with rebound tenderness would be consistent with perforated ulcer. Of course, with any pain that radiates to the back, I want to rule out AAA as well. I have this nagging feeling I'm forgetting something else simple, but unfortunately, I need to hit the road to get back to my rotation site tonight, so will read with interest how this resolved tomorrow...

 

Pancreatitis can radiate to the back as well.

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Worsening symptoms in the supine position could just as well be GI related as it could be cardiac. You could give the GI cocktail and see if there is improvement of symptoms, with her history it couldn't hurt.
Good idea. Patient received maalox:lidocaine:benadryl cocktail, but no relief.

 

T 98.2 P 96 RR 18 O2 Sat 99% on RA BP right arm 112/58 BP left arm 130/69

Gen- Uncomfortable appearing with repeated repositioning in bed

HEENT- PERRL. EOMI. Nares with yellow discharge. MMM

Neck- JVP at 6cm. Carotids without bruits.

CV- 1+ radial and femoral pulses bilaterally. S1 + S2 with this

Pulm- CTAB

Abd- +BS Soft/NT

Ext- No edema

Neuro- CNII-XII grossly intact. No focal deficits.

 

What do you think? What do you want to order/do?

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My d/dx so far:

Pericarditis, possibly headed for Tamponade with those unequal B/Ps on different arms (I would check pulse pressures, she may have been in differing phases of insp/exp)

Thoracic dissection (can also cause pericarditis)

strangulated esophageal hernia

Esophageal perforation

PE

 

So first I'd get a stat portable chest (I would hope this has been done in the ED) to look for dissection/aneurysm (though acute pericarditis/effusion might not show up), I'd be getting a stat TTE as well and a chest CT depending on what I saw on the plain films, look for some malignancy in the chest.

Labs: CMP (r/o uremic pericarditis, d-dimer (elevated in dissection, though not great specificity), CBC w/ diff (look for infection), continue serial cardiac enzymes, could be post-MI pericarditis (Dressler's)

I'd be wondering about TB exposure, maybe CMV, pneumococcus (could get urine strep pneumo or ASO titer, but more important to find out what's going on in her chest right now anyways)

 

 

Great case, thanks for posting this!

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Without a fever it makes me think noninfectious, pending the CBC. Id do a CT chest w/ contrast, assuming creat is ok, to r/o dissection, PE, and other major pathology of the chest. A large PE can mess with the right side of the heart and cause JVP, not sure what to make of the varying BP in the arms.

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Labs: CMP (r/o uremic pericarditis, d-dimer (elevated in dissection, though not great specificity), CBC w/ diff (look for infection)
Na 139, K 4.2, Cl 108, CO2 22, BUN 8, Cr. 0.7

LFTs nl

WBC 13.8, Hct 38, Platelets 420 Diff with 77% neutraphils

 

could be post-MI pericarditis (Dressler's)
Do you think she's having an MI is the first question.

 

So first I'd get a stat portable chest
Portable CXR: Normal mediastinum with aortic notch. No infiltrate or effusion.

 

continue serial cardiac enzymes
The next set of cardiac enzymes is again normal. However, when you heard this (click on the link) you immediately asked the nurse to get another EKG...

 

post-7136-137934850388_thumb.jpg

 

Bedside Echo: Excellent visualization with no significant pericardial effusion or evidence of aneurysm/dissection of proximal aorta. Trace MR.

 

Repeat brachial BPs were equal and initial disparity was likely a red herring.

 

So what is the primary diagnosis? How are we going to treat this woman?

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Hmm, diffuse up-sloping ST elevation with no reciprocal depressions, some PR depression in II, friction rub, no major badness on TTE or CXR, looks like pericarditis! Start NSAIDs and maybe work-up some of the for auto-immune etiology while she's in-house, maybe not if she's got a good PCP? Sounds like it could be viral-associated.

 

http://www.aafp.org/afp/980215ap/marinell.html

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Hmm, diffuse up-sloping ST elevation with no reciprocal depressions, some PR depression in II, friction rub, no major badness on TTE or CXR, looks like pericarditis! Start NSAIDs and maybe work-up some of the for auto-immune etiology while she's in-house, maybe not if she's got a good PCP? Sounds like it could be viral-associated.

http://www.aafp.org/afp/980215ap/marinell.html

 

Excellent. This patient had acute pericarditis. I have never heard such a pronounced friction rub, nor dynamic EKG changes that were so classic. Most cases of pericarditis are idiopathic or viral. From from my readings, work-up is not usually recommended on first episode. As this patient had no evidence of rheumatologic pathology (I went through a rheum ROS with her), I did not send rheum serologies. More likely than not an ANA would have been positive given her age and sex, which wouldn't be clinically relevant. On presenting this case to my attending, he wanted to send a lyme panel (no evidence of conduction delays on serial EKGs or tele) given our location and season. This was negative.

 

Usual pharamocologic treatment entails NSAIDs/high dose ASA. Because of her history of moderate GERD, I wanted to avoid this class, so opted for colchicine. Gave her 1.2 mg loading dose followed by 0.6mg the following day with morphine prn. Her symptoms resolved before the 2nd dose of colchicine and was discharged.

 

The data: http://www.clevelandclinicmeded.com/medicalpubs/ccjm/may2007/saltzman.htm

 

Though this case isn't a mind buster, it highlights the broad differential for chest pain.

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A large PE can mess with the right side of the heart and cause JVP, not sure what to make of the varying BP in the arms.

A large PE could certainly cause right heart strain progressing to right heart failure with increased JVP on exam. When I document JVP on physical exam, it accounts for the 5cm distance to the right atrium. So a JVP of 6cm means that I measured the JVP to be 1cm above the angle of Louis. Abnormal JVP would be more than 8-9cm (or 3-4cm above the angle of Louis).

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