Level 1: Chest Pain – Contrasting Case #3: Patient Information

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 a 25 year old woman, who is brought to the emergency room after a one hour history of chest pain.

HPI: The patient notes severe ‘pressure’ on the right of her chest for the last hour.  It has been constant.  It feels sharp and achy at the same time, and it hurts more if she breathes in deeply or if she coughs or sneezes. She has never had anything like this before. This pain came on all of a sudden this morning while she was washing dishes. Nothing has relieved the pain. She doesn’t feel it anywhere else other than her chest.  She has no known heart disease, diabetes, high blood pressure or high cholesterol. She denies a prior history of blood clots. She has no other medical problems and the only medication she takes is over-the-counter vitamins. She took birth control pills for several years but stopped them about six months before she got pregnant. She smoked 1/2 pack daily for 8 years, but quit while she was pregnant. She had a baby 10 days ago with no complications. She doesn’t use drugs. She has had no recent travel. FmHx: Father died in 80s of complications of a stroke. Mother is alive, age 80, and well.

PE –
Vital signs: BP 110/60, P 120, R 26, T 37.5 C, O2 92% on RA.
General:  The patient is alert and oriented x3. She winces with deep inspiration.
Skin: Normal. No rash. Forehead is diaphoretic
Neck:  Normal.
Pulmonary:  Lungs CTAB. Breath sounds equal bilaterally. Normal effort. No chest-wall tenderness.
Cardiovascular: RRR, rate 120/min. 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: CBC – Normal, CMP – Normal, Troponin I – Normal
EKG: Normal
CXR: Normal
CT Pulmonary Angiography: Thrombus in a lobar branch of the right pulmonary artery