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CASE 2.1

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A 35-year-old female presents with a 1-hour history of chest pain, which resolved spontaneously. The pain is described as a chest pressure radiating to both arms. The patient is a smoker but has no other risk factors (no family history of cardiac disease, hypertension, diabetes, hyperlipidemia, etc.). The patient is diaphoretic and has a normal blood pressure. Physical examination reveals that the patient has tenderness to palpation of the anterior chest wall that reproduces the chest pressure. She is now otherwise free of chest pain and all her lab assays, including cardiac enzymes, are normal.

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Question 2.1.1 Which of the following is true about this patient's physical findings and history?

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A) Pain radiating to both arms makes it unlikely that this patient's pain is cardiac.

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B) The physical findings that are most highly associated with an acute myocardial infarction (AMI) include hypotension, diaphoresis, and a new S3 gallop.

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C) The absence of risk factors makes it unlikely that this patient has cardiac disease.

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D) The fact that the pain is reproducible on palpation of the chest wall effectively rules out cardiac disease.

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E) Based on the information available, further cardiac evaluation is unnecessary.

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Answer 2.1.1 The correct answer is "B." The findings that are most likely to be associated with an AMI are hypotension, diaphoresis, and a new S3 gallop. "A" is not true because pain radiating to both arms can still be associated with cardiac disease. In fact, compared with left arm radiation, right arm radiation or bilateral arm radiation doubles the likelihood of the pain being cardiac (LR 2.3 for radiation to the left arm vs. LR 4.1–4.7 for radiation to the right or bilateral arms). (JAMA. 2005;294(20):2623–2629.) Women with AMI often present atypically and may experience more chest pain radiating to the right arm/shoulder and the anterior neck or with abdominal pain as compared with men. "C" is incorrect. The absence of risk factors is only one consideration in the evaluation of this patient. Smoking, hypertension, family history, etc., do not change the prior probability of cardiac disease enough to allow them to be used to rule out or rule in cardiac disease. Of note, male gender and diabetes DO increase the pretest probability of coronary artery disease (CAD) (luckily our patient is a woman!). Evaluation of pretest probability is important in the diagnostic algorithm, but should be used in addition to, not in exclusion of, clinical judgment and findings. "D" is incorrect. It is true that chest pain reproduced by palpation of the chest wall makes cardiac disease less likely. However, 15% of patients with cardiac disease and 17% of patients with a pulmonary embolism (PE) will ...

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