A 40-year-old man presented to emergency department with a 2-day history of chest pain. He also has a 1-week history of sore throat, runny nose, dry cough, and generalized body aches. Yesterday, he woke up with chest pain, which he describes as a severe, sharp, substernal chest pain that is aggravated by cough, deep breathing, and lying down. No dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitations, or syncope. He is physically active and is training for a 20-mile marathon. He has a history of hypertension, diabetes type 2, and dyslipidemia. No medication allergies. He drinks 1 glass of red wine on most nights. No history of tobacco or illicit drug use. He is on hydrochlorothiazide, metformin, and lovastatin. On examination, he appears to be in moderate distress from the chest pain. Vitals signs are within normal limits. Cardiac examination shows normal heart sounds with a pericardial rub. The remainder of the physical examination is unremarkable. Complete blood count is normal; basic metabolic profile is within normal range. Cardiac enzymes are normal. Electrocardiogram done in the emergency room shows diffuse ST segment elevation without reciprocal changes and PR segment depression in the limb leads. Chest radiograph is within normal limits.
1. What is the diagnosis and treatment of this condition?
His symptoms and signs are typical for acute pericarditis. Patient had chest pain for 2 days, which is sharp, constant, and worsened by position and deep breathing. Electrocardiogram shows diffuse ST elevation without reciprocal changes that helps to differentiate it from myocardial infarction where you will find reciprocal ST depression with evolution of Q waves. Most cases of pericarditis are idiopathic or viral in etiology. Treatment is to begin nonsteroidal anti-inflammatory medication.
One of the most common presenting complaints in the emergency department, clinics, and even in hospital inpatients is chest pain. Several conditions can present as chest pain, and the challenge is in identifying the life-threatening causes from benign conditions.
In patients with chest pain who are not having a myocardial infarction, 50% to 60% of them have musculoskeletal and gastroesophageal disorders as the etiology of their chest pain. Unknown causes and psychiatric condition account for another 8% to 35% of the cases. Realizing this, it is also important to recognize that chest pain is a symptom of some life-threatening conditions that require further investigation and management. Patients who are discharged with a diagnosis of noncardiac chest pain of unknown origin have survival rates of 94% at 10 years and 88% at 20 years.
A thorough history and physical examination can identify the etiology of the chest pain in most cases. In some cases, though, we may need additional testing to confirm or refute a clinical diagnosis.
Characteristics of the pain ...