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 24). In: Sloan PD, Slatt LM, Ebell MH, Jacques LB, eds. Essentials of Family Medicine, 4th ed. Philadelphia, PA: Lippincott, Williams and Wilkins, 2002, 395 - 417. Note: This is the required text for the FM Preceptorship.

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

Case 1

A 35 year old female comes to your clinic with a 1 hour history of chest pain. The pain is described as a pressure radiating to both arms. She is a smoker. No history of hypertension, diabetes, or family history of cardiac disease. She is diaphoretic and 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. 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?

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?

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. 02 saturation is 97% on room air and his pulse is about 130.

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? 

Case 3

A 25 year old female on oral contraceptives comes in complaining that she had a syncopal episode about one hour ago and was transiently short of breath. She notes that her pulse rate was elevated but is now normal. No real chest pain is noted by the patient, but she has vague twinges in her chest when she breathes. No leg swelling or other edema. No fever, chills, cough. Her oxygen saturation is 97%, her pulse is 110 and respiratory rate is 22. The rest of her exam is normal.

Question 1: What are the risk factors for PE? Does this patient have any risk factors?

Question 2: What are the symptoms and signs of PE? Does this patient exhibit any such signs and symptoms?

Question 3: What are the laboratory tests that can help you in the diagnosis of PE? 

Question 4: What is currently the best imaging test for diagnosis PE? What is the role of spiral CT? 

Question 5: Would you Doppler the patient's legs looking for a DVT?