100 Cases in Clinical Medicine

(Rick Simeone) #1



A 34-year-old male accountant comes to the emergency department with acute chest
pain. There is a previous history of occasional stabbing chest pain for 2 years. The current
pain had come on 4 h earlier at 8 pm and has been persistent since then. It is central in
position, with some radiation to both sides of the chest. It is not associated with shortness
of breath or palpitations. The pain is relieved by sitting up and leaning forward. Two
paracetamol tablets taken earlier at 9 pm did not make any difference to the pain.

The previous chest pain had been occasional, lasting a second or two at a time and with
no particular precipitating factors. It has usually been on the left side of the chest
although the position had varied.

Two weeks previously he had an upper respiratory tract infection which lasted 4 days. This
consisted of a sore throat, blocked nose, sneezing and a cough. His wife and two children
were ill at the same time with similar symptoms but have been well since then. He has a his-
tory of migraine. In the family history his father had a myocardial infarction at the age of
51 years and was found to have a marginally high cholesterol level. His mother and two sis-
ters, aged 36 and 38 years, are well. After his father’s infarct he had his lipids measured; the
cholesterol was 5.1 mmol/L (desirable range!5.5 mmol/L). He is a non-smoker who drinks
15 units of alcohol per week.


His pulse rate is 75/min, blood pressure 124/78 mmHg. His temperature is 37.8°C. There is
nothing abnormal to find in the cardiovascular and respiratory systems.

  • A chest X-ray is normal. The haemoglobin and white cell count are normal. The creatine
    kinase level is slightly raised. Other biochemical tests are normal.

  • The ECG is shown in Fig. 2.1.


Free download pdf