Level 2: Chest Pain – Contrasting Case #2: 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 centrally located chest pain. The patient is anxious and short of breath upon exam. He describes the pain as a tearing pain that radiates to the back. The patient also reports abdominal pain along with nausea. He reports 1 episode of emesis after onset of pain. He also reports shortness of breath and anxiousness. The patient reports the chest pain started suddenly while he was lying in bed. It is constant in duration. He denies worsening of chest pain with respiration, exertion, movement, or association with food. He denies any relieving factors. The patient reports several episodes of chest pain over the past few years, but reports resolution of pain upon resting. He reports the pain he is currently experiencing is different in quality than his previous chest pain. The patient denies any recent illness, fever, chills, nausea, or vomiting. He reports chronic cough due to COPD. He reports minor sputum production in the mornings upon waking. The patient reports sputum is white in color and does not contain blood.

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

Physical Exam –

General: 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 (left arm): 100/65, BP (right arm): 125/80 P:125, RR:26, BMI:32, T:99

Respiratory: Patient takes rapid breaths. Lungs are resonant to percussion bilaterally. Vesicular breath sounds present bilaterally. Diffuse wheezes present bilaterally, consistent with COPD. No rales or rhonchi present bilaterally.

Cardiovascular: Tachycardia. Regular rhythm. Heart sounds are distant. No murmurs present. SBP drops 20mmHg upon deep inspiration. Carotid pulses are strong. Pulses are 2+ in upper extremities and 1+ in lower extremities bilaterally.

Tests –

CXR: Widening of aortic knob and mediastinum
EKG: Sinus tachycardia with electrical alternans (consistent with pericardial effusion)
Labs: increased AST, ALT (shock liver due to blood loss), increased creatinine (ischemic changes to renal parenchyma)