MEDizzy - A 63-year-old man with a history of hypertension and

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Cardinal Manifestations and Presentation of Diseases 1

A 63-year-old man with a history of hypertension and hyperlipidemia comes to the emergency department complaining of 1 hour of chest pain that came on at rest. The pain is substernal and radiates to both shoulders. He describes the pain as “diffuse pressure, not sharp” and says he feels nauseated and sweaty. He also feels like the pain improves when he curls up on his left side. His physical examination is notable only for some mild diaphoresis and a heart rate of 105 bpm with blood pressure of 140/ 88 mmHg. All of the following aspects of his history increase the likelihood of acute coronary syndrome EXCEPT:

ExplanationThe answer is C.The evaluation of nontraumatic chest discomfort relies heavily on the clinical history and physical examination to direct subsequent diagnostic testing. The evaluating clinician should assess the quality, location (including radiation), and pattern (including onset and duration) of the pain as well as any provoking or alleviating factors (Figure II-7). The presence of associated symptoms may also be useful in establishing a diagnosis. The quality of chest discomfort alone is never sufcient to establish a diagnosis. However, the characteristics of the pain are pivotal in formulating an initial clinical impression and assessing the likelihood of a serious cardiopulmonary process, including acute coronary syndrome in particular. Interestingly, radiation to the right arm has a greater likelihood of being related to acute coronary syndrome than radiation to the left arm. Of the factors listed, only positional quality of pain (which is often typical of pericardial infammatory disease) lessens the likelihood of acute coronary syndrome. This patient has a high risk given his past medical history and acute complaints.