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Chest Pain & Diarrhea

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History of Present Illness:

A 32-year-old male presents to the ED for an episode of chest pain lasting several hours. He states he has had a diarrheal illness with high fevers for about a week which is being treated with Cipro, which he last took last night.  This morning he had a severe chest pressure across his chest that woke him, but is now gone.  He denies any vomiting, abdominal pain, SOA or other complaints

Vital Signs & Physical Exam:

Vital signs are normal except for a temperature of 102.9 and a pulse of 97 (I use 55-95 as normal).  Physical exam is otherwise normal

Initial Differential Diagnosis:

  • Side effect of Cipro
  • ACS
  • Myocarditis
  • Anxiety
  • Syphilis, the great immitator

Initial Diagnostic Testing:

  • CBC and BMP are normal
  • The EKG is normal.
  • The troponin is elevated at 1.5 and on repeat it is 2.4

QUESTIONS:

  1. What might the elevated troponin signify?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

 

  1. What might the elevated troponin signify?   The troponin could be elevated from myocarditis
  2. What should you do next?  Continue with antibiotics, but consider changing agents to Bactrim or Zithromax.  Consult cardiology.  Get an echo
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below sample page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: Troponin peaked at 4.1, Coronary CT did not show any CAD or coronary calcifications. Echo showed mildly decreased EF at 50%, and a very small pericardial effusion. Stool studies including enteric pathogens, C. Diff, and rotavirus were all negative. The patient was thought to have myocarditis and a diarrheal illness, likely both viral, perhaps due to coxsackie virus

 

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