Triage: Chest pain and arm numbness since last night.
History of Present Illness: A man in his early 30’s with no past medical history presents for chest pain since the prior evening. He has also had a cold for about a week but most of those symptoms seem to be improving. His chest pain is not pleuritic, positional or exertional and does not really radiate anywhere but is associated with numbness in both forearms, moreso on the left. He denies any neck pain or arm weakness.
Vital signs: Pulse 72, BP 145/83, RR 18, temp 98.8
Physical exam: normal including symmetric pulses, no splinting and clear lungs
An ECG is done
Computer Read: Sinus rhythm, Normal ECG
What is the most likely cause of the chest pain in this patient?
- A) ACS
- B) Pleurisy
- C) PE
- D) Dissection
- E) Pericarditis
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THE EMERGENCY MEDICINE POCKETBOOK TRIFECTA
- Emergency Medicine 1-Minute Consult, 5th edition
- A-to-Z EM Pharmacopoeia & Antibiotic Guide, 5th edition
- 8-in-1 Emergency Department Quick Reference, 5th edition
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My ECG interpretation: These is a normal sinus rhythm but the computer is missing subtle diffuse ST elevation that is concave up as well as diffuse PR depression. The ST elevation appears to be more notable in lead II than lead III. There is also a positive Spodick sign, though it is also subtle.
What is the most likely cause of the chest pain in this patient?
- A) ACS
- B) Pleurisy
- C) PE
- D) Dissection
- E) Pericarditis – CORRECT – There are multiple suggestive findings as mentioned above
1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook
Case conclusion: Troponin was about 100x normal at 550 with a repeat of 5000. Due to rapid troponin rise a CTPA and CT coronary angiogram were both done, and both were completely normal