Picture Quiz: Chest pain with an immunological cause
Life threatening causes must be excluded first, say Benjamin James Sieniewicz and Rafe Chamberlain-Webber
- By: Benjamin James Sieniewicz, Rafe Chamberlain-Webber
A 72 year old man presented to the emergency department with five days of intermittent chest discomfort, associated with a tingling pain that radiated down his left arm. He had a history of ischaemic heart disease, and eight years before he had had bypass grafting of two coronary arteries. Other relevant history included type 2 diabetes, hypercholesterolaemia, chronic kidney disease, and surgery for bladder and bowel cancer.
Question 1—What four potentially life threatening diagnoses need to be considered and excluded?
Answer—Acute coronary syndrome; pulmonary embolism; aortic dissection; and tension pneumothorax.
His blood panel showed no evidence of cardiac necrosis (troponin <0.04 μg/l), although the electrocardiogram had some irregularities—T wave inversion in aVL, ST elevation in V1, and ST depression anterolaterally. Because of the possibility of an acute coronary syndrome and admitted the man for further monitoring and investigation.
Question 2—What further investigations would help to establish the cause for this