Case 12: Chest pain

Opening scenario

Hazel Porter, a 35-year-old female; , comes to the emergency department because of chest pain.

Vital signs

• Temperature: 100.4°F (38°C)
• Blood pressure: 110/65 mm Hg
• Heart rate: 105/min
• Respirations: 30/min

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• Act as if you have trouble breathing (lean forward and prop yourself up with your hands on your knees; pause while talking to catch your breath).
• Pretend to have chest pain that gets worse when you breathe in.
• Cough every now and then.
• When the examinee pushes your right foot upward, say that it hurts in your right calf.
• Pretend that it hurts when the examinee presses on your right calf.
• You are not aware of the meanings of medical terms (e.g., ultrasound) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Act very anxious and ask “This is really bad, right?”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• My chest hurts.
• Location
• It is difficult to say exactly, but I think it is on the left side.
• Intensity (on a scale from 0–10)
• It is a 5.
• Quality
• It feels like my chest is really tight and then there is a stabbing pain, too.
• Onset
• It started suddenly this morning after I got out of bed.
• Precipitating events
• I do not think so. I was asleep before it started.
• Progression/constant/intermittent
• It is getting worse.
• Previous episodes
• No.
• Radiation
• No, it is just in my chest.
• Alleviating factors
• Sitting up makes it a little bit better.
• Aggravating factors
• The stabbing pain gets worse every time I breathe in.
• Associated symptoms
• I have a hard time breathing.

Review of systems specific to chest pain and shortness of breath

• Trauma
• No.
• Recent travel
• I was in Japan; for the past 2 weeks. I just got back last night.
• Swelling of the ankles
• My legs felt swollen on the flight back, but they always swell up on the plane, so I did not think anything of it.
• Nausea/vomiting
• No.
• Fever/chills
• I did not take my temperature, but I have been having chills for the past few days.
• Fatigue
• I have been really tired with all the traveling over the past 2 weeks.
• Racing of the heart
• Yes, since this morning.
• Rash/skin changes
• No.
• Cough
• I have had a cough since last week, but it feels even worse today.
  • Productive
  • No.
  • Blood
  • No.
• Recent infections
• Just the cold I got last week in Japan.
• Dizziness
• A little bit if the pain gets really bad.
• Leg pain
• My right leg hurts right now. But my entire body has been achy for the past few days.

Past medical history, family history, and social history

• Past medical history
• None.
• Allergies
• None.
• Medications
• I take a birth control pill and a daily multivitamin.
• Hospitalizations
• Never.
• Ill contacts
• No.
• Past surgical history
• None.
• Family history
• My mom died of a heart attack when she was 40 years old. And my grandma also had a heart attack when she was young, but I do not remember how old she was exactly.
• Work
• I am in charge of buying for a large online retailer. That is why I was in Japan.
• Home
• I live by myself.
• Alcohol
• Not much. Sometimes on the weekends if I go out to dinner with my friends.
• Recreational drugs
• Never.
• Tobacco
• Yes. I smoke about 2 packs a day. I think I started when I was about 15 years old.
• Exercise
• No.
• Diet
• I eat out a lot – BBQ, fried chicken, those kind of things. I know that I do not have the healthiest diet.

• Washed hands
• Used respectful draping
• Neck examination
  • Evaluation of JVD
• Cardiovascular examination
  • Palpation of the radial pulse
  • Auscultation of the heart
• Chest examination
  • Inspection of the chest
    • Increased respiratory effort (use of accessory muscles of respiration)
  • Palpation of the chest
  • Percussion of the lung fields
  • Auscultation of the lungs
  • Examination for fremitus
• Extremities
  • Inspection of the lower extremities
  • Palpation of the lower extremities
    • Right calf tender to palpation
  • Homan sign
    • Positive
  • Examination for pitting edema
  • Palpation of pedal pulses

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee did not repeat painful maneuvers during physical examination.
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered counseling on smoking cessation.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: ”Ms. Porter, I understand your concern.I am very glad that you decided to see me as soon as your symptoms started today. Given your family history and your recent long-distance flight, I would like to rule out that you have a blood clot in your heart or your lungs. I can assure you that we are doing everything in our power to provide you with the best possible care. Once we are done here, we will give you some oxygen and some pain medication to make breathing a little easier. I would also like to draw some blood, take a look at the function of your heart, and take some pictures of your lungs. A technician will come in to perform an ECG. This is a way for us to get a better idea of whether your heart is getting enough oxygen and is moving the way it should. The technician will put little patches on your chest, arms, and legs and then a machine will read the electrical currents that run through your heart. The test does not hurt and does not take long to do. I would also like to get a CT, a computed tomography, of your lungs. This test is very quick and provides us with very detailed pictures of your lungs. It allows us to see if there is a blood clot or an infection there. If anything is unclear at any point while you are here or if you have any questions or concerns, please make sure to let us know. If you would like to have any friends or family here for support today, we would be more than happy to contact them for you. Does that all sound okay? Do you have any questions right now?”

Patient note

Differential diagnoses

1. Pulmonary embolism (PE): This woman has acute-onset dyspnea, pleuritic chest pain, palpitations, tachycardia, and tachypnea after getting out of bed, along with features of a right lower extremity deep vein thrombosis (i.e., tender swollen leg with a low-grade fever and a positive Homan sign). She has a Wells score of 7.5 (1.5 for heart rate > 100/min, 3 for clinical features of DVT, and 3 for PE being more likely than another diagnosis), which indicates a high probability of her having a pulmonary embolism. Smoking, estrogen use (oral contraceptive pill), and especially prolonged immobilization due to a long-distance flight are important risk factors for deep vein thrombosis.
2. Myocardial infarction (MI): MI should always be considered in patients presenting with acute-onset chest pain or chest tightness and dyspnea. Onset of symptoms after waking up in the morning in particular should raise concern for an MI, as approximately 40% of all MIs occur in the early morning hours. This patient also has a positive family history for MI, is a smoker, does not exercise, and eats a high-fat diet, which are important risk factors for underlying atherosclerosis. However, her young age and the features of right lower extremity deep vein thrombosis after prolonged immobilization make PE more likely.
3. Atypical pneumonia: Non-productive, dry cough, dyspnea, low-grade fever, chills, and fatigue are typical clinical features of atypical pneumonia. The condition is more common in smokers. Auscultation is often normal in atypical pneumonia, and the condition can rarely lead to the pleuritic chest pain seen in this patient. However, the features of right lower extremity deep vein thrombosis after prolonged immobilization and the acute onset of pressure-like chest pain make this the least likely of these the differential diagnoses.

Diagnostic studies

• ECG: best initial test for myocardial infarction, which would typically present with ST-elevations. In PE, sinus tachycardia is most often seen, but ECG may also show signs of right ventricular pressure overload (new right bundle branch block, SIQIII pattern).
• Compression Doppler ultrasound of legs: can be used to diagnose potential deep vein thrombosis as a cause of pulmonary embolism
• Transthoracic echocardiography: may show wall motion abnormalities in myocardial infarction. In PE, echocardiography may show signs of right atrium pressure and dilatation and hypokinesis of the right ventricle.
• Chest x-ray: May show diffuse reticular opacity in atypical or interstitial pneumonia. Extensive opacity restricted to one pulmonary lobe with positive air bronchogram is typical for lobar pneumonia. In rare cases, PE presents with typical radiological signs such as the Hampton hump or Westermark sign.
• CBC, ESR, blood cultures: Leukocytosis and elevated ESR are signs of inflammation in pneumonia. Blood cultures are always recommended to detect the causative pathogen in pneumonia.
• Troponin T, CK-MB: Troponin T is the most important, cardiac-specific marker and may be measured 3–4 hours after the onset of myocardial infarction. CK-MB values correlate with the size of the infarction. Increased troponin T can also occur in PE (due to right ventricular overload).
• Arterial blood gas analysis: may show hypoxemia in pneumonia and severe PE
• CT pulmonary angiography: provides high sensitivity, specificity, and immediate evidence of pulmonary arterial obstruction

Other differential diagnoses to consider

• Pericarditis
• Pneumothorax
• Anxiety
• Aortic dissection
• See also differential diagnoses of acute chest pain.