md2besoon
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A 63 year-old male presents to the emergency department after resolution of a 20-minute episode of chest pain, which began while he was raking leaves. The pain was described as a "pressure" sensation. The pain radiated down his arms and into his jaw and was associated with palpitations and dyspnea. The pain resolved shortly after resting. The patient had 3 prior episodes of similar pain today, lasting approximately 10 minutes each, and all with activity. He denies nausea, vomiting, diaphoresis, cough or any other associated complaints, nor is there change in the pain with inspiration or movement. He has had no recent illnesses. His past medical history is significant for diet controlled diabetes and hypertension. He hasn't smoked in "many years" and denies drug use. He presently takes HCTZ and states that he is compliant. Family history is significant for a sister who had an acute MI at age 55. He has no known allergies.
On physical examination he is an anxious, thin male who looks appropriate for age. His vitals are as follows: BP 150/85, pulse is 80, respirations 24/min, room air oxygen saturation 94%, and temperature 37.3. His external jugular veins are not distended. He has basilar crackles ¼ up bilaterally and his chest is nontender to palpation. Cardiovascular exam reveals no murmurs, gallops or rubs. His abdomen is soft and non-tender. His skin is dry and pink. He has equal bounding pulses in all four extremities. The rest of his examination is unremarkable.
View the ECG:
http://www.mdchoice.com/CME/Coronary3/Usa3.jpg
While in the emergency department he says that his pain is returning.
What is your differential diagnosis at this time?
a) Pneumonia
b) Pulmonary Embolism
c) Acute MI
d) GERD
e) Unstable angina
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| ayeshah_l
Forum Elite
Topics: 29
Posts: 284
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PE
GERD
unstable angina
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| luckiest
Forum Senior
Topics: 12
Posts: 82
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History:age,activity relate crush chest pain 20 min,fam his,HT
PE:may be pulmonary edema
ECG : ST depess in II,III,aVF and V2-V6 >Global myocardial injury
1.unstable angina
2.acute MI
3.PE ,Sat O2 94% RR=24
The patient has smoked for many years possible the norm of O2sat is low. But there is tachypnea
chest tenderness is not priciple diagnosis.in this patient there's no risk of PE( hypercoagulable,preg)
Hypotension&tachycardia maybe not found if it 's not massive PE.
In this case I think if NTG cannot solve the chest pain then you cannot R/O PE.
:8
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| miky
Forum Senior
Topics: 16
Posts: 99
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I'd say PE. tacypnea, slight fevers and crackles.
Unstable angina usually progresses sooner or later to MI.
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