55 A 58-Year-Old Male With Chest Pain


Case 55

A 58-Year-Old Male With Chest Pain



Seth Politano



A 58-year-old male with a history of type 2 diabetes mellitus and hypothyroidism presents with a chief complaint of 2 days of intermittent chest pain.



What do you consider in your differential diagnosis of the chest pain in this patient?


A broad differential diagnosis should be undertaken with a chief complaint of chest pain (see Table 55.1). Particular attention should always be focused first toward life-threatening causes of chest pain, then other serious (but not immediately life-threatening) causes, then finally less ominous causes.




What other historical elements can you use to elicit the history in a patient with chest pain?


With some of the life-threatening causes of chest pain, it is important to note that “pain” might not be the patient’s chief complaint. Patients often describe a stabbing, crushing, pressurelike, or tearing sensation. Therefore, sometimes using alternate words to ask a history, including “chest discomfort,” may be useful. Asking the patient if he or she has current chest pain is helpful for triage. Always obtain the usual elements, including prior events, onset/timing, location, severity, intensity, and alleviating and aggravating factors, as well as baseline functional status and exercise capability/limitations. It is important to undertake a complete medication history, family history, and social history and to elicit historical evidence of features that are characteristic for life-threatening causes of chest pain. Table 55.2 lists historical features of life-threatening causes of chest pain.



After asking the patient salient features of conditions that are life-threatening, one can then investigate other causes of chest pain. A general review of systems will oftentimes elicit the relevant symptoms seen in these disorders. Specific questions to ask include those related to fever, weight loss, cough, edema, abdominal pain, food association, joint pain, rash, weakness in extremities, and psychiatric screening.



The patient indicates he has never had this chest pain before. He was mowing his lawn when the chest pain first occurred. He rates the pain as 6 to 8 out of 10, lasting a few minutes at a time, with at least five episodes before presentation. He says the pain is pressurelike and points to his sternum when describing the area of the pain. It is exacerbated by walking around his home and improves when resting. It is nonradiating in nature. He takes metformin 500 mg twice a day and levothyroxine 25 mcg daily. He has a 30-pack-year smoking history and uses no illicit drugs or alcohol. He is an only child. His mother and father are both alive, in their 80s, and both have hypertension. He denies fever, cough, joint pain, or weight changes.



What physical exam clues can you use with a chief complaint of chest pain?


Table 55.3 lists physical exam findings with select causes of chest pain.



Physical exam reveals a blood pressure of 148/92 mm Hg, with a pulse rate of 82/min. He is afebrile and his oxygen saturation is 97% on room air. He has no jugular venous distension, and his pulse rate is regular with no murmurs or rubs appreciated. Lung exam reveals normal breath sounds with no adventitious features. There is no abdominal pain, lower extremity edema, or rashes.



TABLE 55.3


Physical Exam Findings With Select Causes of Chest Pain








































Condition Clinical Hints/Findings
Myocardial Infarction/Ischemia May have S3 (as seen in patients with acute heart failure) or S4 (as seen in patients with underlying coronary artery disease or hypertension) on exam. Murmur from onset of valvular disease or wall rupture. May also present with signs of low-output (hypotension, altered mental status) or volume overload (crackles, jugular venous distention, edema).
Aortic Dissection Blood pressure difference in arms, murmur of aortic insufficiency, objective weakness in lower extremities, decreased pulses in lower extremities. Complications include hypotension, and exam findings consistent with pleural effusion and ischemia.
Pneumothorax Decreased breath sounds, hyperresonance to percussion. Can see tracheal deviation with tension pneumothorax.
Cardiac Tamponade Jugular distention, decreased breath sounds, hypotension, pulsus paradoxus.
Pulmonary Embolism Tachycardia, tachypnea, hypoxia. Can have signs of deep vein thrombosis (DVT) and pleural effusion. Loud P2, fixed split S2.
Esophageal Rupture Tachycardia, palpable subcutaneous emphysema, Hamman’s sign (audible crunch with heart sounds).
Pulmonary Hypertension Loud P2, fixed split S2, heave, eventual right-sided heart failure (jugular venous distention, pulsatile liver, edema).
Congestive Heart Failure Jugular venous distention, hepatojugular reflux, S3, S4, crackles, exam evidence of pleural effusion, may hear wheezing, pulsatile liver/hepatomegaly/ascites, dependent edema, pulsus alternans.
Pericarditis Friction rub. May be tachycardic and febrile. Lymph node, joint exam, and skin exam may reflect causes (i.e., autoimmune diseases, infection, malignancy, uremia). Kussmaul’s sign (increased jugular venous distention or lack of decrease with inspiration) if constrictive.
Pneumonia Fever, bronchial breath sounds, rhonchi, dullness to percussion, friction rub, signs of effusion.
Aortic Stenosis Lack of normal carotid upstroke, systolic crescendo–decrescendo murmur which is loudest at the right upper sternal border that radiates to supraclavicular/carotid region. S4 may be present, and heart sounds may be paradoxically split or reveal the absence of A2 heart sounds.




Given historical components, what is this patient’s pretest probability of underlying coronary artery disease?


The pretest probability for underlying CAD is useful for risk stratification in the outpatient setting and can guide the need for noninvasive testing. It also provides you with a tool to consider if CAD is the likely cause of the patient’s presentation with chest pain. Table 55.6 lists estimated risks for CAD.



TABLE 55.6


Estimated Risk of Coronary Artery Disease



































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Jun 15, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on 55 A 58-Year-Old Male With Chest Pain

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Typical Angina Atypical Angina Nonanginal

Male Female Male Female Male Female
30-39 Years 59 27 29 10 18 5
40-49 Years 69 37 38 14 25 8
50-59 Years 77