M3 Preceptorship: student version of discussion cases: Chest Pain

Learning Objectives:

• Define the accuracy of the initial EKG, labs, etc., in the diagnosis of cardiac disease in the ED or office
• Define the role and significance (or lack thereof) of risk factors such as diabetes, family history, smoking and hypertension in the decision of whether or not to admit a patient for cardiac disease
• Define the roles of various diagnostic tests in the diagnosis of possible pulmonary embolism
• Discuss the differential diagnosis of chest pain

Suggested Readings:
Green LA, Rodgers PE, Chest Pain (Chapter 9). In: Sloan PD, Slatt LM, Ebell MH, Smith MA, eds. Essentials of Family Medicine, 6th ed. Philadelphia, PA: Wolters Kluwer/Lippincott, Williams and Wilkins, 2012, 99-112.

Panju AA, et al.  Is This Patient Having a Myocardial Infarction?  JAMA 1998;280:1256-63. May be accessed at: http://jama.ama-assn.org/cgi/reprint/280/14/1256.pdf

Ebell, MH, Evaluation of Chest Pain in Primary Care Patients. Am Fam Physician.  2011 Mar 1; 83 (5):603-605.

CASE 1

A 35 year old woman comes to clinic with a 1 hour history of chest pain and diaphoresis that began while she was sitting at her desk.  She describes a pressure radiating to both arms.  She is a smoker.  No history of hypertension, diabetes, or family history of cardiac disease.  She has a normal blood pressure.  She blames the diaphoresis on the fact that it is hot outside with a high humidity, and she has just walked in from the parking lot.  She looks relatively calm and comfortable.  She has no murmurs, gallops or rubs on exam.  Lungs are clear.  She has no tenderness.  Her EKG shows nonspecific ST-T changes without other abnormalities.

Question 1: What is the differential diagnosis of chest pain?

Question 2: What is the differential of cardiac chest pain?

Question 3: What historical features help you better characterize it as cardiac versus noncardiac
chest pain?  What is this patient’s risk according to the clinical decision rule in the Ebell article?

Question 4:  Which has the highest likelihood ratio of being associated with cardiac disease, right arm radiation, left arm radiation or pain to both arms?

Question 5:  What physical findings increase the likelihood that chest pain is due to a cardiac source?

Question 6: What lab tests or other studies do you want to order and how will you use the results in your decision making?

Question 7:  How might women present differently than men?  What are special challenges with female patients in the evaluation of chest pain? 

Question 8:  How might the presentation change for a diabetic patient?  An elderly patient?

Question 9:  How would you manage this patient?

CASE 2

55 year old man with no prior history of cardiac disease presents stating he feels as though he is going to die.  He notes chest pain that reached a maximum intensity about 10 minutes after it started.  It is described as a pressure that radiates to his left arm.  He complains of dyspnea, is diaphoretic and appears in distress.  He has a long history of smoking and hypertension but a negative family history.  When questioned, the patient notes that he also has a past history of depression but has been fine for the past 10 years or so.  His job is stressful but no more than usual, and he usually handles things pretty well.  His blood pressure is 142/94.  02 saturation is 97% on room air and his pulse is about 130. His pain is not reproducible. 

Question 1: What signs and symptoms does this patient display that are consistent with cardiac
disease?

Question 2: What signs and symptoms does this patient have that are associated with panic
disorder?

Question 3: What would you do for this patient?