Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is an 18 year old woman of normal build.
HPI: Pain on the right of chest for the last few days. It has been constant in a mild way, but worse when the patient twists or turns. It feels sharp and achy at the same time. It is not a terrible pain, but it is a bother, especially with certain movements and sometimes if the patients breathes deeply. She has never had anything like this before. The pain came on gradually and the patient doesn’t remember doing anything specific to cause it. Nothing has relieved the pain. There is no radiation of the pain. The patient denies diaphoresis or shortness of breath. No palpitations, lightheadedness, fever, cough, neurological changes, calf pain or swelling, abdominal pain, nausea, or vomiting. No recent travel. PMH: No medical problems. Takes no medications. No known heart disease, diabetes, hypertension, or hypercholesterolemia. FH: No family history of heart problems. Grandfather died in 80s of complications of a heart attack. Grandmother alive, in her 80’s, and well. Father, age 48, has high blood pressure and high cholesterol. Mother, age 48, has anxiety. One brother, age 19, healthy. SH: Smokes cigarettes rarely but not daily. Drinks a beer per month. Does not use other drugs.
PE –
Vital Signs: BP 110/60, P 76, R 16, T 37C, O2 98% on RA.
General: The patient is alert and oriented x3. She appears in no acute distress.
Skin: Normal. No rash.
HEENT: PERRLA. EOMI. Normal.
Pulmonary: Lungs CTAB. Breath sounds equal bilaterally. Normal effort. There is tenderness to palpation over the right 2nd, 3rd and 4th costochondral junctions that reproduces the patient’s symptoms.
Cardiovascular: RRR. No murmur. Equal pulses and perfusion throughout. Blood pressure is equal in both arms.
Abdominal: There is no abdominal tenderness. No rebound. No guarding. No bruising or skin changes, no caput medusa, liver edge is normal, negative Murphy sign. No splenic enlargement. Normal bowel sounds.
Back: No spinal tenderness, no muscular tenderness, no CVA tenderness.
Extremities: No edema, no calf tenderness, no discoloration.
Neurological: Normal.
Labs: Chest x-ray – normal, d-dimer – normal