100 Cases in Clinical Medicine

Question

• What should be done?

CASE 28: CHRONIC CHEST PAIN

History

A 25-year-old woman is complaining of chest pain. This had been present for 2 years on and
off. The pain settled for a period of 6 months but it has returned over the last 10 months. The
pain is usually on the left side of the chest, radiating to the left axilla. She describes it as a
tight or gripping pain which lasts for anything from 5 to 30 min at a time. It can come on
at any time, and is often related to exercise but it has occurred at rest on some occasions,
particularly in the evenings. The pain is usually associated with shortness of breath. It makes
her stop whatever she is doing and she often feels faint or dizzy with the pain. Occasionally
palpitations come on after the start of the pain. Detailed questioning about the palpitations
indicates that they are a sensation of a strong but steady heart beat.

In her previous medical history she had her appendix removed at the age of 15 years. At
the age of 30 years she was investigated for an irregular bowel habit and abdominal pain
but no specific diagnosis was arrived at. These symptoms still trouble her. She has sea-
sonal rhinitis. Two years ago she visited a chemist and had her cholesterol level measured;
the result was 4.1 mmol/L. In her family history her grandfather died of a myocardial
infarction, a year previously, aged 77 years. Several members of her family have hay fever
or asthma. She works as a medical secretary. She is married and has no children.

Examination

On examination, she has a blood pressure of 102/65 mmHg and pulse of 78/min which is reg-
ular. The heart sounds are normal. There is some tenderness on the left side of the chest, to
the left of the sternum and in the left submammary area. The respiratory rate is 22/min. No
abnormalities were found on examination of the lungs. She is tender in the left iliac fossa.

• Her electrocardiogram (ECG) is shown in Fig. 28.1.


• She asked to be referred for a coronary arteriogram to rule out significant coronary
  artery disease.

INVESTIGATIONS

I aVR V1 V4

aVR V2 V5

aVF V3 V6

II

III

V1

II

V5

Figure 28.1

Electrocardiogram.