A 42 Year Old Woman with History Of Diabetes Presents With Chest Pain - Case Study

A 42-year-old registered nurse is seen because of pain in the chest. She describes a “pain in my heart” and points to a 1-cm area above the left breast. The pain is intensified by deep breathing, coughing, recumbency, and twisting motions. It has lasted continuously for 2 days. Three days ago, she noted extreme fatigue and shortness of breath lasting for 24 hours. Findings from a complete physical examination are normal.
1. What is the most likely diagnosis in this patient, and why?

As you are about to discharge this patient, her husband tells you he is concerned about his wife because her sister underwent coronary bypass surgery at 44 years and her brother at 34 years. Because the pain has some features of pericarditis, you decide to do an ECG. It shows normal sinus rhythm with Q waves in the inferior leads and diffuse ST-segment elevation.

2. What is your diagnosis, and w hat would you do?

Answers:


1. What is the most likely diagnosis in this patient, and why?
Chest wall pain or pericarditis would be the most likely initial diagnosis in this patient.

• Angina pectoris is uncommon in women in this age-group, and this pain is not anginal in character. 
• Aortic dissection pain is typically very severe from the start, “sharp, tearing” and can radiate to the back. 
• Acute cholecystitis manifests clinically with right upper quadrant tenderness and occasionally a palpable gallbladder. 
• Pneumonia and pleurisy are differentiated because of the association with fever and cough with abnormal chest examination. 
• A pneumothorax is associated with acute shortness of breath findings of hyperresonance to percussion and diminished breath sounds on the affected side. 
• Pain arising from the chest wall is the most common cause of chest pain in any age-group, and often has no discernible cause. It can be reproduced by pressure over the painful area. 
• Pericarditis is often accompanied by a friction rub. This rub has a coarse, “leathery,” or “walking on crunchy snow ” sound, with accentuation during systole as well as early and late diastole (how ever, sometimes only one or two components are audible).Inspiration intensifies the rub. Its features often include a precise localization and tenderness on palpation over the affected area. Deep breathing, position changes, and specific body movements such as twisting often accentuate the pain. Its duration varies from a few seconds to days. 

Therapy is nonspecific, consisting of reassurance and simple analgesics or nonsteroidal drugs.

2. What is your diagnosis, and what do you do? (After the ECG)
This patient probably had a silent inferior MI a few days ago and now presents w ith postinfarction pericarditis. The Q w aves are inferiorly related to the MI while the diffuse ST-segment elevation is compatible w ith pericarditis.

Additional history is that she has had type 2 diabetes mellitus for 20 years and a recent cholesterol screening at a health fair. Her LDL cholesterol was 242 mg/dL, consistent with familial heterozygous
hypercholesteremia.

The patient should be admitted for telemetry observation. Troponin I is likely to be elevated and should be drawn.

When you ask the patient to sit up, lean forward, and exhale, a two-component pericardial friction rub is noted.

Aspirin should be given for her MI and can be used at much higher doses to treat the concomitant pericarditis. Ibuprofen is the NSAID of choice for pericarditis; how ever, its use should be avoided in the setting of an acute MI as it could interfere w ith scar formation. The remainder of her treatment is
as for patients with acute MI, except that this infarction is older and acute reperfusion is not indicated.

Silent ischemia is more common in diabetes. Although women younger than 50 years do not often have symptomatic coronary disease, this advantage is neutralized by the presence of diabetes. When evaluating patients w ith chest pain, attention to CAD risk factors is paramount.