Case 14: Chest pain

Opening scenario

Max Harris, a 45-year-old male; , comes to the emergency department because of chest pain.

Vital signs

• Temperature: 100.3°F (37.9°C)
• Blood pressure: 135/75 mm Hg
• Heart rate: 105/min
• Respirations: 20/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

• Hold your left chest as if you have moderate pain in that area.
• You are not aware of the meanings of medical terms (e.g., ECG) and ask for clarification if the examinee uses them.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Tell the examinee that you do not know the names of your medications, only the first letter of each one (as in the “Past medical history” checklist below).

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
• I have pain in my chest.
• Location
• On the left side.
• Intensity (on a scale from 0–10)
• A 6.
• Quality
• It is a dull pain.
• Onset
• It started 30 minutes ago.
• Precipitating events
• It started suddenly when I was running to catch the bus.
• Progression/constant/intermittent
• The pain is there all the time, and it has gotten worse since it started.
• Previous episodes
• None.
• Radiation
• No.
• Alleviating factors
• No.
• Aggravating factors
• I think it might be a little worse when I move or lay down.
• Associated symptoms
• I have felt short of breath since the pain started.

Review of systems specific to chest pain and shortness of breath

• Trauma
• I play football. I was tackled by another player yesterday.
• Recent travel
• No.
• Swelling of the ankles
• No.
• Nausea/vomiting
• No.
• Fever/chills
• I feel like I may be running a fever today but this is the first day.
• Fatigue
• No.
• Racing of the heart
• It seems like my heart is beating faster right now. It usually only feels that fast when I am playing football.
• Rash/skin changes
• No.
• Cough
• No.
• Recent infections
• I had a runny nose 2 weeks ago.
• Dizziness
• No.

Past medical history, family history, and social history

• Past medical history
• My doctor told me that I have high blood pressure, and my cholesterol is a little high, too.
• Allergies
• None.
• Medications
• I take vitamins. And I take prescription medications for my blood pressure and cholesterol, but I forgot the names. One starts with an “R” and one with an “A.”
• Hospitalizations
• Never.
• Past surgical history
• None.
• Family history
• None.
• Work
• I work as a bartender in a club downtown.
• Home
• I live alone. I have a girlfriend.
• Alcohol
• No, I do not drink any alcohol.
• Recreational drugs
• I take amphetamines every now and then.
  • Amphetamine intake (duration, frequency, last intake)
  • For 5 years; , maybe about twice per week; . I took 1 pill yesterday afternoon.
• Tobacco
• Yes. A pack a day for 15 years.
• Exercise
• I run once a week.

• Washed hands
• Used respectful draping
• Neck examination
  • Evaluation of JVD
  • Auscultation of the carotid arteries
• Cardiovascular examination
  • Inspection of the chest
  • Palpation of the chest
  • Palpation of apical impulse
  • Palpation of the radial pulse
  • Auscultation of the heart
• Chest examination
  • Auscultation of the lungs
• Extremities
  • Examination for pitting edema

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

Suggested response to challenge: “Mr. Harris, I will need to run some tests before I know exactly what is causing your chest pain. As your doctor, I would like to get a more complete picture of your health before deciding on the best course of action. Part of that process involves finding out which medications you are currently taking. Who might I be able to ask about the names of your medications?”

Patient note

Differential diagnoses

1. Acute coronary syndrome (ACS): Exercise-induced, acute-onset, left-sided chest pain in association with shortness of breath and tachycardia is highly suggestive of angina pectoris. This patient has multiple risk factors for cardiac ischemia, such as hypertension, hypercholesterolemia, and amphetamine use. Unstable angina is defined as angina pectoris occurring for the first time (new-onset angina) or angina that worsens over time (crescendo angina), which would be consistent with this patient's symptoms; a myocardial infarction would also present with increased troponin T and CK-MB levels and/or ECG changes (see ECG changes in STEMI). Both conditions fall under the umbrella term acute coronary syndrome, making it the most likely differential diagnosis here.
2. Pericarditis: Chest pain, tachypnea, and dyspnea are typical symptoms of pericarditis. The chest pain is typically worse when the patient is in a supine position and/or alleviated by leaning forward. Although pericarditis often occurs following upper respiratory tract infections, the onset of pericarditis is usually less acute and this patient does not have other typical symptoms, such as a friction rub.
3. Rib contusion: Chest pain following a physical trauma such as being tackled is often due to musculoskeletal injuries. While pain aggravated by movement is consistent with a rib contusion, the sudden but delayed onset of the pain as well as the dyspnea in this patient make the diagnosis less likely.

Diagnostic studies

• ECG: to assess for signs of acute myocardial ischemia and pericarditis
• CBC: leukocytes would be elevated in pericarditis
• Echocardiography: can show signs of pericardial effusion in pericarditis; helpful for assessing wall motion abnormalities, LV function, and possible complications in patients with unstable angina
• Urine toxicology: to assess for amphetamines and other drugs that can cause chest pain (e.g., cocaine)
• Troponin T, CK-MB: would be elevated in myocardial infarction and rarely in pericarditis but negative in unstable angina
• Coronary angiography: to detect (and possibly treat) a coronary artery stenosis

Other differential diagnoses to consider

• Pneumothorax
• Pulmonary embolism
• Rib fracture
• See differential diagnoses of acute chest pain.