A young woman with chest pain

by Bob Stuntz in

Let's welcome Dr. Shafer back to the blog.  Between being a chief resident and being accepted in to a critical care fellowship, she has another interesting case presentation for you.  Some really interesting learning points on this one.  Stay tuned for the answer! 


Dr. Shafer: 

    A 28 year old female presents to the ED with a chief complaint of chest pain that started acutely at 3am this morning and awoke her from sleep. She reports that pain is in the center of her chest and is constant, nothing makes it better or worse, and it is not positional.  She woke up vomiting this morning and additionally feels short of breath and is diaphoretic. She states that she feels weak all over and has bilateral arm numbness. She has not had any recent URI symptoms. She does not abuse alcohol but she does use marijuana occasionally. She smokes ½ pack of cigarettes per day. There is no family history of cardiac disease or of sudden deaths. She has no prior past medical history and takes no medications. 

    Vital signs are as follows: HR 108, BP 165/98, RR 18, Oral Temp 98.6F, oxygen saturation is 100%. On exam she pale, diaphoretic, is leaning forward clutching her chest and appears uncomfortable. Lungs are clear to auscultation bilaterally, heart is normal rate and rhythm without murmurs/rubs/gallops. She has normal strength and sensation to light touch in bilateral upper and lower extremities, cranial nerves are intact, and has 2+ radial pulses bilaterally. 

    Her EKG is shown below. Cardiology was immediately consulted due to the patient's appearance; they evaluated the patient at the bedside and diagnosed the patient with pericarditis. CT thorax was obtained which revealed no dissection or PE.  A bedside echocardiogram reveals a normal EF with concerns for apical wall motion abnormalities.  Pertinent labs revealed a white count of 18.8, troponin 3.15, lactic acid 3.6, and a normal BNP.

What is on your differential at this point?

What further testing could be done to evaluate the patient?  

Have a diagnosis in mind?