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