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 22 year old female with no known medical conditions brought to the ED by her roommate. She has had 30 minutes of substernal, crushing chest pain accompanied by dyspnea, anxiety, palpitations, and nausea.
HPI: The patient’s roommate reports they were sitting at home eating breakfast when the patient said something wasn’t right while she rubbed her chest. This has never occurred before, the pain is not affected by position, and there was no preceding illness. Nothing makes her symptoms better or worse and she hasn’t taken anything for the pain. Patient reports no significant life stressors and no history of anxiety. Upon further questioning of the patient’s friend, she admits they were at a party until 6 a.m. where the patient snorted cocaine. She states the patient was having a great time and seemed fine until breakfast. The patient has used cocaine 2 prior times beginning in the past 1 year when she started college.
PE:
Vitals- BP 146/100 mmHg, P 100, T 100.4 F, RR 20, BMI 21 kg/m2
General- Patient is disheveled, anxious, and in distress
HEENT- Pupils are dilated and reactive to light, no nystagmus
CV- Tachycardic, heart sounds difficult to distinguish due to tachycardia. No JVD, no edema. Pain is not reproduced with palpation of chest.
Resp- Tachypnea, increased respiratory effort, clear to auscultation bilaterally
Abdomen- Bowel sounds present, nondistended, nontender to deep palpation
Rest of exam is WNL
Tests:
ECG – See below
Cardiac biomarkers – See below
Toxicology screen – positive for cocaine and marijuana
