A Patient with Chest Pain



A Patient with Chest PainA 58-year-old man comes to the Yale Emergency Department complaining of substernal chest discomfort. He states that it has occurred early in the morning when he walks outside to get the newspaper and diminishes when he rests after about 5-10 minutes. He describes it as a dull ache in his midsternal area that doesn't radiate anywhere but causes him to feel like he can't catch his breath. He states that it began about five months ago and hasn’t changed in intensity or frequency but he is concerned because his brother (age 52) recently “died of heart attacks.” He denies headaches, visual problems, cough, epigastric pain or any known medical problems. He quit smoking 6 months ago, but drinks an occasional beer or two with dinner. He works in a pizzeria and lives at home with his wife and four children all of whom are healthy. Family history is also noted for hypertension and non-insulin dependent diabetes in his brothers. His mother died of a stroke; his father died of a heart attack at age 82.P.E. reveals an anxious WM. T 996; P 110; R 20; BP 160/92. Skin - normal. LN - nonpalp. HEENT - normal. Chest - clear. COR - JVP 7 cm; RRR 1/6 SEM at LLSB radiating to L 2nd IC space. + S4; - S3 or rub. Abd - soft without organomegaly or tenderness. G/R - benign with normal rectum; heme negative. Neuro - nonfocal.LABS:Na 138, Cl 104, K 3.9, HCO3 25, Cr 1.1, glucose 180Hb 14.0, Hct 42.0, WBC 8.3, plts 355KUA: clear/1.016/no cells or castsEKG: S tach/110 rate/normal intervals, no ST-T wave changes are notedCXR: normal heart size/clear lung fieldsQuestionsWhat is your most likely diagnosis and why?Name at least 5 other common entities that need to be considered in the differential diagnosis? What aspects of the history, physical, laboratory features would you look for to suggest these other possibilities?Describe the anatomic blood supply to the heart and the basic pathogenesis of cardiac ischemia.What major risk factors for ischemic cardiac disease? Which are particularly relevant to this patient?Would there be any diagnostic benefit from doing an exercise stress test on this patient? Describe the basic principles of this test. What if the patient cannot exercise? What if his baseline EKG showed a left bundle branch block?What are the major classes of medications available for this patient? Describe their basic mechanisms of action, modes of administration and potential side effects.Is coronary angiography indicated for this patient? What are its major indications, benefits and risks?What would be an indication to consider coronary angioplasty or bypass surgery? Describe their benefits, long term success rates, and risks.Although employed, the patient does not have health insurance. How might his lack of insurance influence your treatment and follow-up care? ................
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