Case 1 – Heavy Chest Pain

49 year old male that presented to the ED with a two day history of chest pain and shortness of breath – it was intermittent, with no pattern and he did not really think much of it. Today the pain had changed, it had become constant and more severe. He described the pain as central and heavy. It had been ongoing for about 45 minutes and was about 5-6/10 in severity. The pain came on gradually and did not radiate. There was some mild associated SOB but no nausea, vomiting, sweating, collapse. He had no previous episodes of chest pain or similar symptoms.

He had no medical history, did not take any regular medications. He was a non-smoker, drank alcohol socially and denied ever taking illicit or recreational drugs. He was unaware of his cholesterol and base line blood pressure having not seen a GP for a while. There was no worrying family history.

Examination

He was alert and orientated but looked anxious and mildly uncomfortable. His vital signs were within normal limits, he was afebrile, had a capillary of 11.5 m/mol. His examination was unremarkable, his chest was clear with equal air entry and no chest wall tenderness. Heart sounds were normal, there was no peripheral oedema and pulses were normal in all limbs.

Differential Diagnoses

DIAGNOSIS RATIONALE
Cardiac
Acute Coronary Syndrome (ACS) Likely
Thoracic aortic dissection Pain not sudden, severe or tearing, didn’t radiate through to back. Normal pulses and no ‘fleeting neurology’
Pericarditis Pain not pleuritic or positional, not tachycardic, no suggestive ECG changes
Respiratory
Pulmonary Embolism (PE) no pleuritic pain, no haemoptosis, normal Sp02, not tachycardic, no evidence of DVT, no history of clots

Wells: low. PERC: negative

Peumonia No productive cough, chest clear, no fever, WCC, CRP and CXR normal
Pneumothorax Pain not pleuritic, normal equal air entry, normal CXR
Gastric
Gastric reflux No burning sensation, no belching, not related to food
Other
Costocondritis/muscular pain No recent illness, no trauma, no pain on moving, no chest wall tenderness

 

Investigations

  • ECG – normal sinus rhythm @ 78, normal ST segments. Serial ECG remained normal.
  • CXR – lung fields clear, no pneumothorax, no cardiomegaly.
  • Troponin – elevated 375
  • Baseline bloods – normal

 

Final diagnosis

Non-ST Segment Myocardial Infarction (NSTEMI)

Useful links for this case:

The Resus Room podcast on troponins and troponin rule outs and interval likelihood ratios

Wells and PERC from the Royal College of Emergency Medicine

SIGN and NICE guidance for ACS

ECG vodcast

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