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Positional Chest Pain*3

“BRADY” DOWN FOR THE REST

History:

A 42-year-old male presents to the ED for ~24 hours of pleuritic left-sided chest pain that is worse when he lies flat. He denies any fever or cough but did have a cold about a month ago.  About 3 weeks ago he had rib pain on the other side that lasted about a week.  His doctor told him it could be shingles without the rash and treated with Famvir and it resolved after about a week.

Exam:

Vital signs are normal.   Exam is normal.  There is no rash, hyperpigmentation or abnormal heart or lung sounds.  His extremities are without edema or chords.

Initial differential diagnosis:

  • Pericarditis
  • Pulmonary Embolism
  • Acute Coronary Syndrome

Initial EKG:

  • Computer read: Normal Sinus Rhythm, Left Axis Deviation
    • Do you agree?
    • What do you think the diagnosis is?

“BRADY” DOWN FOR THE EKG ANALYSIS & 1-MINUTE CONSULT

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EKG ANALYSIS & CASE CONCLUSION:

  • The computer read is correct.  The computer is quite good at determining the axis. Otherwise there are no significant abnormalities
  • Case Conclusion: Chest x-ray was normal. D-dimer was elevated so CT chest was done which showed no pulmonary embolism, but did show a left lingular infiltrate and a small right pleural effusion.  The troponin was slightly elevated and was unchanged on repeat.  Cardiology saw the patient and diagnosed pericarditis.  Remember pericarditis has a normal EKG in about 30% of cases.  See highlighted area of page shot below for more information.
  • The patient was admitted and treated for the adjacent pneumonia and the pericarditis resolved.

Quick Essentials on the EKG topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

Source: The Emergency Medicine 1-Minute Consult Pocketbook   

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