Level 2: Chest Pain – Contrasting Case #1: 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 68 year old male patient presents to the ER with reports of chest pain. The patient is anxious and short of breath upon exam. The chest pain is unilateral and located over the left hemi-thorax. He describes the pain as a sharp, stabbing pain, but denies radiation of the pain. The patient reports the chest pain has progressed gradually over the past week. The patient reports fever and chills over the past week. He also reports coughing up sputum that is yellow in color. He denies hemoptysis. He denies worsening of chest pain with exertion, movement, or association with food. He reports chest pain is worse upon taking a deep breath. The patient reports several episodes of chest pain over the past few years, but reports resolution upon resting. He reports the pain he is currently experiencing is different in quality than his previous chest pain. He reports chronic cough due to COPD.

Illnesses: COPD, Angina, HTN, HLD, Obesity, DM type 2, GERD
Medications: Albuterol and ipratropium inhalers prn, Nitroglycerine tablets prn, Amlodipine 10mg qd, Simvastatin 40mg qd, Metformin 850mg bid, Ranitidine 150mg qd

Mother passed away at age 75 of lung cancer; Father passed away at age 72 of MI; reports extensive family history of diabetes and hyperlipidemia

Social Hx –
Tobacco: 45 pack year history (45 years x 1 ppd)

Physical Exam –
Male patient appearance consistent with age. Patient is in moderate distress due to shortness of breath and chest pain. Patient is restless and unable to become comfortable during interview and exam.

Vital Signs: BP:140/95, P:110, RR:26, BMI:32, T:101.2

Tachypnea present. Dullness to percussion over the inferior portion of the left lung. Resonant percussion notes present over right lung fields. Bronchial breath sounds present over the inferior portion of the left lung field. Vesicular breath sounds present over the right lung fields. Diffuse wheezes present over all lung fields, consistent with COPD.

Tachycardia. Regular rhythm. S1 and S2 of normal intensity. No murmurs, rubs, or gallops.

Tests –

CXR – areas of hypodensity and hyperinflation, consistent with COPD; consolidation present over left lower lobe of lung
EKG – sinus tachycardia; possible pathological Q waves present to simulate prior ischemic changes.