CASE 51: CHEST PAIN
History
A 62-year-old man is admitted to hospital with chest pain. The pain is in the centre of the
chest and has lasted for 3 h by the time of his arrival in the emergency department. The
chest pain radiated to the jaw and left shoulder. He felt sick at the same time. He has a his-
tory of chest pain on exercise which has been present for 6 months. He has smoked 10 cig-
arettes daily for 40 years and does not drink alcohol. He has been treated with aspirin and
with beta-blockers regularly for the last 2 years and has been given a glyceryl trinitrate
spray to use as needed. This turns out to be two or three times a week. His father died of
a myocardial infarction aged 66 years and his 65-year-old brother had a coronary artery
bypass graft 4 years ago.
He has no other previous medical history. He works as a security guard.
Examination
He was sweaty and in pain but had no abnormalities in the cardiovascular or respiratory
systems. His blood pressure was 138/82 mmHg and his pulse rate was 110/min and regular.
His electrocardiogram (ECG) is shown in Fig. 51.1.INVESTIGATIONS
aVR V1 V4V2V3 V6II aVL V5IIIIII aVFFigure 51.1Electrocardiogram.
He was given analgesia and thrombolysis intravenously and his aspirin and beta-blocker
were continued. His pain settled and after 2 days he began to mobilize. On the fourth day
after admission, he became more unwell.
On examination, now his jugular venous pressure is raised to 6 cm above the manubrioster-
nal angle. His blood pressure is 102/64 mmHg, pulse rate is 106/min and regular. His tem-
perature is 37.8°C. On auscultation of the heart, there is a loud systolic murmur heard all
over the praecordium. In the respiratory system, there are late inspiratory crackles at the
lung bases and heard up to the mid-zones. There are no new abnormalities to find elsewhere
on examination. His chest X-ray is shown in Fig. 51.2.