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Mrs. G is a 68-year-old woman with a history of hypertension who arrives at the emergency department by ambulance complaining of chest burning that began 6 hours ago. Two hours after eating, moderate (5/10) chest discomfort developed. The pain begins in her mid-chest and radiates to her back. She initially attributed the pain to heartburn and used antacids. Despite multiple doses over 3 hours, there was no relief. Over the last hour, the pain became very severe (10/10) with radiation to her back and arms. The pain is associated with diaphoresis and shortness of breath. The pain is not pleuritic. She thinks that she is having a heart attack.

Mrs. G takes enalapril for hypertension. She lives alone, is sedentary, and smokes 1 pack of cigarettes each day for the past 30 years.

image At this point, what is the leading hypothesis, what are the active alternatives, and is there a must not miss diagnosis? Given this differential diagnosis, what tests should be ordered?


Mrs. G is an elderly woman with hypertension and a 30 pack-year smoking history who is experiencing acute, nonpleuritic, chest pain. Referring to Figure 9-2, multiple “must not miss” diagnoses including ACS, AAS, and PE, must be considered. Given the patient’s presentation, age, and risk factors, ACS is most likely. AAS is also possible given the patient’s history of hypertension and the pain’s radiation to her back, though the progressive onset of the pain is somewhat atypical for AAS. Though PE remains on the differential, there is nothing in the presentation that specifically raises the likelihood of this must not miss diagnosis. Other less life-threatening diagnoses, such as esophageal spasm, GERD, and pancreatitis, should also be included on the differential diagnosis (Table 9-5).

Table 9-5.Diagnostic hypotheses for Mrs. G.

While the physical exam cannot reliably distinguish ACS, AAD, and PE, a brief, yet thorough, exam is recommended to identify hemodynamic instability, highly specific signs of a life-threatening diagnosis, or precipitating causes. Referring again to the algorithm in Figure 9-2, the first pivotal point is to distinguish between an ST-elevation myocardial infarction (STEMI) ...

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