A Change of Heart

A CLINICAL PROBLEM-SOLVING article by Thomas Tsai from University of Colorado, Denver.
 A 57-year-old teacher with a history of hypertension presented to an urgent care center with nonradiating chest pressure and light-headedness. Her chest pressure had begun soon after she had arrived at work that morning, when she was physically threatened by a parent of one of her fifth-grade students. Her symptoms improved with rest immediately after the event but then worsened by the end of the day.
 The patient had a history of well-controlled hypertension. She had smoked approximately five cigarettes daily for 30 years, rarely drank alcohol, and reported no illicit-drug use.
On initial evaluation, the patient reported slight chest pressure but was not in acute distress. Her blood pressure was 83/50 mm Hg, her heart rate was 110 beats per minute, and her respiratory rate was 14 breaths per minute. Pulse oximetry revealed an oxygen saturation of 99% while she was breathing 2 liters of oxygen through a nasal cannula. Auscultation of the chest revealed a loud, crescendo systolic murmur.
 Chest pressure may suggest any of several disease processes, ranging from benign conditions to life-threatening emergencies. In the presence of hypotension, the initial evaluation must focus on ruling out the latter.
 This patient's hypotension and tachycardia suggest the early stage of shock and thus warrant urgent diagnostic testing and management.
 In this case, the electrocardiographic findings are consistent with an acute myocardial infarction, but other conditions that are associated with ST-segment elevation and may thus mimic myocardial infarction must also be considered. [Original Article]

鑑別診断の列挙

• Chest pressure may suggest any of several disease processes, ranging from benign conditions to life-threatening emergencies. In the presence of hypotension, the initial evaluation must focus on ruling out the latter, which include an acute coronary syndrome, aortic dissection, pulmonary embolism, esophageal rupture, and tension pneumothorax.

Key featureの記述

• Key features of apical ballooning syndrome are the absence of obstructive coronary artery disease in the setting of characteristic “ballooning” of the left ventricle from severe anteroapical akinesis and hypercontractility of the basal segments.

意外と、hypertensionとhypotensionの聴き取りが難しい。