Mr. Rosetti presented with left arm pain and chest pain that he has had for years. He came in today stating that his chest pain and arm pain has changed and over the past few days he has pain when he wakes up and intermittently throughout the day. He takes Procardia XL 60 mg every day for  blood pressure,  isosorbide dinitrate 40 mg three times a day for angina, and one or two nitroglycerine pills when he has chest pain." HE does not smoke, drink or do any drugs. He denies injury and denies shortness of breath or dyspnea. I assessed Mr. Rosetti and his exam was rather benign. S1/S2 heart sounds could be heard. Breath sounds were clear. I ordered an EKG, a cbc, cmp, and a troponin right away. I wanted to ensure that he was not having an NSTEMI. All of his labs were within normal limits. Next, I ordered a chest x-ray and a CT chest to ensure there was no pneumonia or PE that could be causing pain. Both of those tests were negative. I ordered an Echo to assess his heart function and his EF was 40-45%. Finally, I ordered a stress test in which he was unable to complete due to pain and tachycardia along with EKG changes. Based on all of these findings I have come up with three differential diagnoses which include but are not limited to:

·     Unstable angina: Tabor & Whitmore (2018), explain that unstable angina occurs due to an acute obstruction of the coronary artery without myocardial infarction. These patients can present with chest pain/burning, left arm pain/numbness/tingling, angina that becomes more frequent even when resting, shortness of breath and more. In order to properly diagnose angina, it is important to obtain a troponin (if first one is negative may want to repeat in 8-12 hours), a CK-MB level, Chest x-ray, Echocardiogram and a CT chest to ensure the patient is not experiencing a life-threatening aortic dissection.  Patients with unstable angina should be admitted to the hospital, given aspirin and Plavix for antiplatelet management and nitroglycerin for the pain if not hypotensive or have not used a phosphodiesterase type 5 inhibitor within 24-48 hours. If the patient is experiencing unstable angina along with an NSTEMI then they need to have a cardiac catheterization performed within 24-48 hours of being admitted into the hospital for and necessary PCI.

·     Pericarditis: occurs when the pericardium of the heart becomes inflamed causing fluid buildup and irritation (Ismail, 2020). Patients that are suffering from pericarditis often complain that they have chest pain when they take a deep breath or lay down and it resolves if they sit up or lean forward. In order to diagnose pericarditis an EKG can be performed showing widespread saddle shaped ST elevation with PR depression. Laboratory tests that can be performed are a c-reactive protein as this will most often be elevated due to the inflammation. Patient’s must have two of the following in order to diagnose pericarditis: pericardial friction rub, widespread ST elevation and/or PR depression and a new pericardial effusion. Patients with pericardial effusions should be instructed to not exercise for at least 3 months, NSAIDs (Ibuprofen 600mg TID x1-2 weeks) and PPIs are used in conjunction to help with the pain.

·     GERD: Gastroesophageal reflux disease (GERD) can present with the same symptoms that Mr. Rosetti was experiencing. It is estimated that 18-28% of Americans have GERD (Clarett & Hachem, 2018). GERD occurs when stomach contents reflux into the esophagus and this can cause burning in the chest/esophagus. GERD is most often diagnosed based on the symptoms that the patient is having and are worse when the patient is laying down. An EGD can be performed as well to help confirm that the patient is suffering from GERD. In order to treat GERD patients should be placed on either an H2 blocker or a PPI to help reduce the acid that the patient is producing. If those work the patient will not need a further work up.

Based on his diagnosis of Unstable angina Mr. Rosetti should undergo a stress test and PCI to prevent further ischemic events from occurring in the future. He will then need to follow closely with his cardiologist to perform routine evaluations to ensure that he does not have any new obstructions developing. Weight loss and diet can also help decrease his cholesterol in turn decreasing the plaque that is building up in his arteries and help with blood pressure management. The patient can also be placed on Plavix to help with preventing an MI from occurring in the future.

References:

Clarrett, D., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri medicine. Retrieved April 15, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6140167/

Ismail, T. (2020, January). Acute pericarditis: Update on diagnosis and management. Clinical medicine (London, England). Retrieved April 15, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964178/

Tabor, L., & Whitmore, T., (2018). Coronary Artery Disease. Retrieved from