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CLINICAL REVIEW: G Sodeck, B Partik, and H Domanovits Interactive case report: A 42 year old man with acute chest pain BMJ 2003; 326: 920 [Full text]

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Response

raul e. garcia jimenez   (25 April 2003)

Acute Coronary Syndrome

Sudipta Maitra   (25 April 2003)

Acute Coronary Syndrome

HAKIM ABID HUSSAIN, Gazanfar Ali, Tanweer Masood.   (25 April 2003)

A 42 year old man with acute chest pain possibly due to Prinzmetal’s angina

Christos Zavos   (25 April 2003)

Chest pain,differential diagnosis

marc j mattys   (25 April 2003)

Unstable Angina

Sanjay Suman   (25 April 2003)

Let's be honest: we don't know

Steve Goodacre   (25 April 2003)

A 42 years old with chest pain

Adullah M. A Shehab   (26 April 2003)

Interactive case response:

Malvinder S Parmar   (26 April 2003)

No definitive diagnosis yet but needs urgent management

Mohammed S Abouzeid, RIYADH, SAUDI ARABIA KINGDOM.   (26 April 2003)

A 42 year old man with acute chest pain ( unstable angina)

Lubna A Al-Ansary   (26 April 2003)

Insufficient data to jump to conclusions

Anthony N Glaser   (26 April 2003)

What type of hospital am I at?

Andrew G. Robinson   (26 April 2003)

Following are answers

himmatrao Saluba Bawaskar   (26 April 2003)

Acute Coronary Syndrome

JYOTI RAMNIK PAREKH   (26 April 2003)

It can be disscecting aneurysm of the Aorta

Karthik M   (26 April 2003)

Aortic dissection in a hypertensive patient

Joanna N Tenkorang   (26 April 2003)

aortic dissection until proven otherwise

M D Dominic Bell   (26 April 2003)

CLOSE FOLLOW UP WILL HELP

ANJANELU.S CHITTA   (26 April 2003)

Treat as cardiac untill proven otherwise.

Chris topher L. Larmour   (26 April 2003)

Acute Chest Pain

Padmakumar N Pillai   (26 April 2003)

Aortic dissection

Bernardino Roca   (26 April 2003)

?mi,?acute pancreatitis,?pulmonary embolism

krishna kumar jada   (26 April 2003)

acute coronary syndrome

Dr. S. Ranjan   (26 April 2003)

Treat as a precordialgia (angina)

Vitor S Hipolito   (26 April 2003)

Suspect Disecting Aortic Aneurism

Mark R Hambly   (26 April 2003)

gastroesophageal reflux disease

malik rehman abdul   (26 April 2003)

acute miocaidium infarct

rosio guerra   (26 April 2003)

treat as a case of dissecting aortic aneurysum

DR.ZAKI HUSSAIN KHAN   (26 April 2003)

exlude worst

Dragan Trivanovic   (27 April 2003)

is this aortic dissection

ravindhar vodela, OL1 2JH   (27 April 2003)

chest pain

nico de paola   (27 April 2003)

Treat as Acute Coronary Syndome until proven otherwise

Sanjay P Ramdany   (27 April 2003)

Response

William Parsonage   (27 April 2003)

Acute coronary syndrome

Alejandro S Kufert   (27 April 2003)

Aortic dissection

seyed amin zamiri   (27 April 2003)

Urgency MI

Miguel FE Derijcke   (27 April 2003)

Aortic dissection definitely can't be excluded

Shuk Yi Annie Hui   (28 April 2003)

Dissecting Aortic Aneurysm must be Excluded

Nathan P. Gottehrer   (28 April 2003)

Minor opinion

Regina B Stroebele   (28 April 2003)

Myocardial Sarcoidosis

Michael D Innis   (28 April 2003)

Radiologist in the byline...

Andrew G. Robinson   (28 April 2003)

Aortic dissection

shujauddin khokhar   (28 April 2003)

TYPICAL OF CARDIAC ARRHYTHMIAS

kumar R S bhamidimarri   (28 April 2003)

patient with AMI

ariefiansyah -, -   (28 April 2003)

Could it be pancreatitis?

Hsu Phern Chong   (29 April 2003)

the troubling case

hernan combessies   (29 April 2003)

Managing Chest Pain

Sheikh M Haq   (29 April 2003)

Cardiac unless proven otherwise but HOW??

S BAJWA   (29 April 2003)

Agatha Christie?

Alistair Howitt   (29 April 2003)

Abdominal causes should be considered too.

Deepak Kejariwal   (29 April 2003)

Patient permitted his details to be published

Marcus Müllner   (29 April 2003)

Aortic Dissection

GAMAL ALFITORI, nsh stoke-on-trent   (29 April 2003)

chest pain - ANXIETY/POLTIMI?

yahaya yusuf aniki   (30 April 2003)

thoracic dissection

fergus joseph dignan   (30 April 2003)

WPW vs AORTIC DISSECTION

KUMAR RS BHAMIDIMARRI   (30 April 2003)

AS USUAL NOT SURE ABOUT THE DIAGNOSIS

VATSALA S VARADHARAJAN   (30 April 2003)

acute aortic dissection

manfredo turcios, tegucigalpa,honduras.c.a .zc 504   (30 April 2003)

angina

sadaf salahuddin   (30 April 2003)

Acute Coronary syndrome

Adel H Regaila   (30 April 2003)

It should be acute coronary syndrome

Dr.M.Thirughnanam Muthukumarasamy   (30 April 2003)

Aortic dissecting aneurysm

Mauricio Mejia, none   (30 April 2003)

?PERICARDITIS

JM Rumbold   (30 April 2003)

NON

ZAMAN AMJAD, NON   (30 April 2003)

Unstable angina

Dr.Juan Landaburu   (1 May 2003)

chest pain

francis William Doyle   (1 May 2003)

A 42 year old man with acute chest pain

Marin Marinovic   (1 May 2003)

peter hartl's condition

Amin O Sharieff   (1 May 2003)

Rule out pancreatitis and aortic dissection

Carolina Acuña   (1 May 2003)

Acute chest pain

Jose E. Roel   (1 May 2003)

GP commentator's response

Alistair J Howitt   (1 May 2003)

R/O ACS then think about DES

hoda kavosi   (2 May 2003)

42 yr old with unstable angina

Alexander F Browne   (2 May 2003)

Acute Coronary Syndrome?!!

Shabbar Bukhari   (2 May 2003)

Emergency consultants response

Harald Herkner   (3 May 2003)

the one diagnosis that should not be missed

Samer A M Nashef   (3 May 2003)

acue chest pain

shyama rathore   (3 May 2003)

Chest Pain

Akanu abass Obasi   (4 May 2003)

Aortic dissection in a hypertensive man

Mohamad Abdelsalam Abdelkader   (9 May 2003)

response from rizgary hospital

mothafar abdulrahman habib   (9 May 2003)

Pancreatitis?

Letterio Rizzo   (11 May 2003)

Obscure diagnosis w/symptoms presenting as chest pain

Richard C Berglund, MD   (11 May 2003)

not seem to be acute

alparslan sahin   (15 May 2003)

Acute coronary syndrome

Heong Keong Goh   (15 May 2003)

Chest pain 42 year old man

Stephanie Mullings   (15 May 2003)

Retrosternal pain-normal ECG

Boudewijn J G G De Wilde   (19 May 2003)

EXCLUSION

ashwaq alhadithi   (21 May 2003)

Dissection of the thoracal aorta

Oliver Lammel   (23 May 2003)

acute aortic dissecying aneurysm

anil maurya   (27 May 2003)

Re: Patient permitted his details to be published

Hugh de Glanville   (3 June 2003)

Re: Re: Patient permitted his details to be published

Beth Bennett   (27 June 2003)

Response

Suzete V. Mayo   (24 November 2003)

IT IS DIFFICULT TO SAY AS NO SINGLE DIAGNOSTIC TEST TO CONCLUDE DIAGNOSIS

Mohammed Azizuzzaman   (20 May 2004)

my opinion

Laurentiu Iamandi   (28 February 2007)

Response 25 April 2003
raul e. garcia jimenez, Internal Medicine Attending hospital general Occidente .Av zoquipan 1050, zapopan jalisco mexico, 45050 Send response to journal: Re: Response	IAM inferior. Pulmonary Embolism Hiatus Hernia DX. cpk-mb, troponin, tgo, dhl, chest film, angiogram of coronary arteries, pulmonary gammagram, new ekg hourly, To his wife I would say to her " be calm , probably he is having a coronary syndrome, We ARE DOING OUR BEST, AND HE IS GOING TO UNDERGO SOME TESTS BEFORE REACHING A DEFINITIVE DIAGNOSIS, AND SHOULD BE HOSPITALIZE AND RECEIVE OXYGEN, REST, ASPIRIN, AND CONTINUING MONITORING OF HIS HEART BEAT AND A CARDIOLOGIST CONSULTANT WILL BE READY TO EXAMINE HIM. Competing interests:   None declared
Acute Coronary Syndrome 25 April 2003
Sudipta Maitra, Registrar,Internal Medicine,Suraksha Hospital, Salt Lake City, Kolkata , India. 700091 Send response to journal: Re: Acute Coronary Syndrome	1. Acute coronary syndrome. 2.Cardiac enzymes including Trop T /I and Bed side echo. 3. He prbably has got partial blocked in a artery supplying a part of the heart. Competing interests:   None declared
Acute Coronary Syndrome 25 April 2003
HAKIM ABID HUSSAIN, REGISTRAR MEDICAL COLLEGE,SRINAGAR,KASHMIR 110001, Gazanfar Ali, Tanweer Masood. Send response to journal: Re: Acute Coronary Syndrome	This gentleman will be diagnosed in the ER as having an acute coronary syndrome. The subsequent subclassification will depend on ECG and evidence of release of cardiac maromolecules. On the basis of the temporal profile of the chest pain and the ECG he will be diagnosed at this stage to have either a non ST segment elevation MI (NSTEMI) or an unstable angina. However as we go down the acute coronary syndrome protocol we have still to keep other diagnosis in consideration especially the ones which can be life-threatening and require immediate management eg an acute aortic dissection. Competing interests:   None declared
A 42 year old man with acute chest pain possibly due to Prinzmetal’s angina 25 April 2003
Christos Zavos, Senior House Officer Anticancer Hospital of Thessaloniki, 7 Ipsilandi St, GR-553 37, Triandria, Thessaloniki, Greece Send response to journal: Re: A 42 year old man with acute chest pain possibly due to Prinzmetal’s angina	EDITOR – I have read with interest the interactive case report by Sodeck et al (1). The patient’s symptoms are compatible with myocardial ischaemia, since the antacids and proton pump inhibitors had no effect on the epigastric pain, which was gradually aggravating and moreover it was radiating in his back. The possibility of a pain of musculoskeletal origin is also eliminated, because tizanidine was ineffective as well. The ECG revealed slightly elevated ST segments (0.1 mV) in leads I, aVL, V2, and V3, without presence of abnormal Q segments. These findings may be compatible with epicardial ischaemia or acute pericarditis, although the auscultation did not reveal signs of pericarditis. The patient was treated with beta-blockers, which are very widely used in patients with angina. However, they did not seem to have offered any help to the patient. The only type of angina in which beta-blockers are contra-indicated is the variant (or Prinzmetal’s) angina pectoris. The latter diagnosis is also consistent with the fact that the patient experienced these symptoms at night or at his office (not on physical exercise). Additional examinations could include a chest x-ray and a heart echogram to exclude the possibility of pericarditis, careful monitoring with a Holter device, and a coronary angiogram for the detection of potential obstructions in the coronary arteries. A stress ECG may also be needed at a relatively later stage. The patient’s wife should be advised to report new or changing symptoms to the doctor at once, and to encourage him to quit smoking, to limit the caffeine in his diet, to reach and maintain his ideal weight eating foods that are low in cholesterol, low in fat, and high in complex carbohydrates and fibre. Finally, beta-blockers should be discontinued, and changed to calcium channel blockers. Sublingual nitrates could be prescribed during attacks, although they are not always successful in Prinzmetal's angina, and abrupt withdrawal can provoke spasm. Christos Zavos, MD Theageneion Anticancer Hospital of Thessaloniki, Greece e-mail: czavos@hotmail.com References: 1. Sodeck G, Partik B, Domanovits H. A 42 year old man with acute chest pain. BMJ 2003;326:920 Competing interests:   None declared
Chest pain,differential diagnosis 25 April 2003
marc j mattys, anesthesiologist ajaccio,corsica Send response to journal: Re: Chest pain,differential diagnosis	The patient has a dissection of his thoracic Aorta. Competing interests:   None declared
Unstable Angina 25 April 2003
Sanjay Suman, Specialist Registrar in Medicine for Elderly Ipswich Hospital NHS Trust IP3 8NL Send response to journal: Re: Unstable Angina	1. My initial working diagnosis is unstable angina. This is based on clinical presentation, history of smoking and hypertension.The slight elevation of ST segments seen in some leads may point to a diagnosis of Prinzmetal angina. The differential diagnosis at this stage should include a Pulmonary embolism (PE) and acute pericarditis. 2. Further investigations should include a Troponin-I assay, Chest x- ray, blood sugar, lipid profile and D-Dimer in addition to routine blood tests. If the troponin is raised he should be referred for an urgent coronary angiogram. The possibility of acute pericarditis necessiates an echocardiogram and finally if the above two possibilities are ruled out a ventilation perfusion scan may be needed if the D-Dimer is raised. 3. I will discuss the possibility of an underlying coronary artery disease and explain the presence of risk factors. It is also important to reassure her that ECG does not indicate a barn door acute myocardial infarction.The possibility of acute pericarditis and PE shoud be discussed. I will also explain the need for further investigtions. Competing interests:   None declared
Let's be honest: we don't know 25 April 2003
Steve Goodacre, Health Service Research Fellow Emergency Department, Northern General Hospital Send response to journal: Re: Let's be honest: we don't know	Patients presenting to the emergency department with acute chest pain have an approximate 14% prevalence of acute myocardial infarction (AMI). Diagnoses such as musculoskeletal chest pain and gastro-oesophageal pain are frequently made, but difficult to prove by routine diagnostic testing. Anxiety and panic disorders are common (prevalence~20%) and often under- diagnosed. Aortic dissection is uncommon. In this case the absence of diagnostic ECG changes (>1mm ST elevation) suggests that the probability of AMI is somewhat lower, around 4-5%. This probability is raised slightly but the presence of sweating on examination, but other clinical findings are of limited diagnostic value. Hence the balance of probabilities is that Peter has a benign cause for his chest pain. Yet the risk of AMI (5-10%) is not insignificant. Non- AMI coronary syndromes should also be considered, and aortic dissection, although unlikely, cannot be discounted. Investigation for coronary syndromes requires are period of observation and cardiac enzyme testing (preferably a troponin), followed by an exercise treadmill test. In a very well-resourced healthcare system observation could be accompanied by ST- segment monitoring, and alternatives to exercise testing, such as radionuclide scanning or even coronary angiography, could be considered. Investigations for aortic dissection are likely to depend on local availability of investigations and expertise. Again, rational use of healthcare resources may mean that specific tests for aortic dissection are only undertaken if a chest radiograph is abnormal or clinical signs develop. Any explanation to Peter and his wife should candidly reflect the current uncertainty regarding the diagnosis. Categorical statements about serious pathology can be very difficult to revoke. What is the most likely diagnosis? In real life the most probable diagnosis is a non-specific, benign cause, possibly exacerbated by anxiety. As this is a case report in the BMJ, my bet is that it is aortic dissection, or perhaps something even more unusual. Competing interests:   None declared
A 42 years old with chest pain 26 April 2003
Adullah M. A Shehab, Lecturer in cradiovascular medicine University Hospitals Birmingham Send response to journal: Re: A 42 years old with chest pain	The most likely diagnosis is angina pectoris which is commonly association with hypertension and smoking. Certainly I would investigate to exclude coronary artery syndrome. Ideally, I would stress his heart once above is excluded. Competing interests:   None declared
Interactive case response: 26 April 2003
Malvinder S Parmar, Medical Director, Internal Medicine Timmins & District Hospital, Timmins, Ontario, Canada Send response to journal: Re: Interactive case response:	1. The most likely diagnosis in this gentleman with various cardiovascular risk factors who presents with fleeting chest pain for two days with severe onset of chest pain with radition to back and associated diaphoresis and with essential normal ECG, is to rule out a dissection of aortic aneurysm. That would be first diagnosis needed to rule out in view of the character of the pain. Yes, acute coronary syndrome is a possibility and that is an important diagnosis in the differential and needs to be ruled out as well. In any case, there is no indication of thrombolysis in this gentleman at present, even if it is an acute coronary syndrome. 2. Chest X-ray is not mentioned (Was the information deliberately left out) - One should look for widening of mediastinum. The important investigation in this man is to perform urgent CT scan of chest and abdomen with contrast to rule out the possibility of aortic dissection. In addition, to stabilizing the patient - serial ECG and cardiac enzymes including Troponin. CT to rule out aortic dissection is important because of the character of pain and in case few hours later, he had associated ST segment elevation with pain and then if he requires thrombolytic therapy. 3. What to tell the wife: I would discuss the above possibilities and that he will be admitted to CCU and would discuss the investigations to be done and also assure that at this time there is no indication for thrombolytic therapy. At this time, I would also give him intravenous metoprolol 5 mg q 5 minutes X3, as tolerated, morphine for pain control and to alleviate associated apprehension and start him on intravenous nitroglycerine drip (for two reasons)for BP and for anti-anginal effect and to reduce preload until the CT is done and dissection is ruled out. I would not anticoagulate the patient at this time and wait for CT results. Malvinder S. Parmar Competing interests:   None declared
No definitive diagnosis yet but needs urgent management 26 April 2003
Mohammed S Abouzeid, SENIOR REGITRAR,FAMILY & COMMUNITY MEDICINE DEPARTMENT RIYADH MILITARY HOSPITSAL (RKH),, RIYADH, SAUDI ARABIA KINGDOM. Send response to journal: Re: No definitive diagnosis yet but needs urgent management	THE HISTORY OF HYPERTENSION ,SMOKING AND CHEST PAINS IN A 42 YEAR OLD MAN WOULD POINT STRONGLY TOWARDS ACUTE CORONARY SYNDROME.HOWEVER,THE ECG FINDINGS ARE NOT CONCLUSIVE AT THIS STAGE.THEREFORE ONE MUST PUT ALL THE POSSIBILITIES AND SHOULD INCLUDE BESIDE THE ACUTE CORONARY SYNDROME, OTHER CARDIOVASCULAR PROBLEMS EG AORTIC DISSECTION,AND OTHER RARE NON VASCULAR PROBLEMS .FUNCTIONAL CAUSE SHOULD ALWAYS BE AT THE BOTTOM IN A PATIENT WITH SUCH HISTORY. INVESTIGATIONS SHOULD INCLUDE URGENT BLOOD TESTS FOR CARDIAC ENZYMES(TOPONIN,CK,ALT,LD)BLOOD SUGAR ,UREA &ELECTROLTES,FULL BLOOD COUNT.ECG MONITORING ,CHEST X RAY,CARDIAC ECHO WILL ALSO BE NEEDED.ARRANGEMENTS WITH THE CARDIOLOGISTS FOR CORONARY ANGIOGRAPHY AND FURTHER TESTS WILL DEPEND ON THE INITIAL TESTS RESULTS AND THE PROGRESS OF THE CONDITION. I WOULD EXPECT HIS WIFE(NURSE) TO BE EXTREMELY WORRIED THEREFORE I WILL HAVE TO BE BOTH EMPATHETIC AND SYMPATHETIC.I WILL TELL HER AT THIS STAGE WE ARE NOT SURE OFTHE DIAGNOSIS AND BECAUSE OF THE NATURE OF HIS PAINS AND THE FACT THAT HE IS HYPERTENSIVE AND SMOKER WE NEED TO EXLUD ACUTE CARDIOVASULAR PROBLEMS AND ALSO TO SEARCH FOR ANY OTHER POSSIBLE CAUSES THEREFORE WE NEED TO ADMIT HIM .I WILL TACTFUL BUT HONEST IN ANSWERING HER QUESTIONS AND ASK HER IF SHE NEEDS ANY SORT OF HELP AT THIS TIME AND TRY TO HELP HER. Competing interests:   None declared
A 42 year old man with acute chest pain ( unstable angina) 26 April 2003
Lubna A Al-Ansary, Consultant family physician, King Khalid University Hospital, King Saud University, Riyadh, Saudi Ar Dept of Family & Community Medicine, College of Medicine, King saud University, P.O. Box 2925, Riyad Send response to journal: Re: A 42 year old man with acute chest pain ( unstable angina)	Q1. What is the most likely diagnosis? A1. Unsatable angina Q2. What further investigations would you suggest? A2. Serum lipids & other blood tests to assess & modify his cardiovascular risk are important to carry out BUT not urgent. The most important & urgent investigation(s) would be cardiac catheterization to assess the following: a. the patency of the blood vessels (stents can be used if needed & if suitable, b. the cardiac muscles in terms of its perfusion & mobility. Q3. What should you tell his wife at this stage? A3. That she did a good job by bringing him to the hospital & that he is in good hands now. There is no evidence of acute MI till now (hoping that this will alleviate her concern). If she demands further information, I'll explain to her that the chances are that he has unstable angina. It is called unstable (as opposed to stable angina) because it has become more frequent that the usual angina & it might progress to something else. I'll consider that she's a nurse & therefore might have some pertinant medical background that needs to be explored BUT I must keep in consideration that she's a wife who is anxious about her husband & might not comprehend many of the terms (jargon) that are used by health professionals. Competing interests:   None declared
Insufficient data to jump to conclusions 26 April 2003
Anthony N Glaser, Private practice of family medicine Summerville, SC 29483, USA Send response to journal: Re: Insufficient data to jump to conclusions	1 - Most likely diagnosis? Acute MI (given that he has 0.1mV ST elevation in 2 contiguous leads). However there are plenty of other contenders: esophageal spasm, unstable angina, costochondritis, dissecting aortic aneurysm, cholecystitis, cholelithiasis, pulmonary embolism (PE), pericarditis, all exacerbated by anxiety. Although he's only 42, his pretest likelihood of an MI is substantial given his comorbidities, but as he is being presented in a journal by staff at a teaching hospital, his pretest likelihood of a "zebra" is also high! 2 - Further investigations? Given his symptoms and minimal, but ominous, EKG changes, it would be hard to argue with a decision to go to an emergent cardiac cath, if available, perhaps best done after a stat ultrasound to rule out a dissecting aortic aneurysm which (with a PE) would be the most immediately life-threatening possibility. This assumes that his EKG _has_ changed - if a prior EKG were available, and it showed the same minimal ST elevation, the picture would be very different. If a cardiac cath is not chosen, he certainly needs serial cardiac enzymes (CK,CK-MB, troponin) q6-8 hours, continuous EKG monitoring; I would also want a CBC, electrolytes, lipid panel, chest X-ray, D-dimer, PT and INR; I would consider a VQ scan, as an acute PE would also be life- threatening. A more thorough history and exam would be helpful: what was he doing when the pain occurred, did it radiate to the arms, has he been under stress recently, does he use any other substances except tobacco (cocaine?), what does he think is going on? Is the pain reproducible on palpation? Is there a pleuritic component? Family history? GI symptoms? 3 - What to tell his wife? I would tell her that she was obviously worried that he is having an MI, and she is right to be concerned about this - we therefore plan procedures and tests to see if this is the case or not. Not only that, but we will treat him too - the cath would allow prompt PTCA or stent placement if necessary, and we will give him aspirin, oxygen, nitroglycerin and pain medications, a statin, and any other treatments that might be needed on the basis if our findings. Competing interests:   None declared
What type of hospital am I at? 26 April 2003
Andrew G. Robinson, resident IM Vancouver, BC Send response to journal: Re: What type of hospital am I at?	This patient has a broad differential diagnosis (as anyone who attend morning reports can attest)! The possibility of an acute coronary syndrome certainly exists, although one would have wanted to have seen changes on the EKG. An 18 Lead EKG may add something in this case, and I would also send bloodwork for serial troponins, and repeat the EKG. While there is no mention of pulsus paradoxus, JVD etc., I would certainly check for these. Given that the blood pressure is the same in both arms, this lowers the probability of dissection. However, the pain radiating to the back increases this probability. I would order a chest X-ray (PA) to determine if there is any mediastinal widening. If I were in a hospital with CT scanning, I may order a CT scan of the thoracic aorta to rule out dissection, and to look for other intrapulmonary causes. If I was 8 hrs away from the nearest CT scan or echo, I probably would transfer this patient (assuming no other diagnosis jumped up at me). Sooooo- most likely diagnosis ACS: do 18 lead EKG & serial enzymes. Also worry about Aortic Dissection, do CXR and CT-Scan (or MRI or TEE if available). Would also make sure that we are not missing a pancreatitis etc., would throw off an amylase etc. I would tell the patient/family that we are concerned about his health, that we do not have evidence at this time that he is having a heart attack, and that we must watch him carefully and do more testing. Competing interests:   None declared
Following are answers 26 April 2003
himmatrao Saluba Bawaskar, Clinical researcher Mahad, riagad 402301 India Send response to journal: Re: Following are answers	1- it is unstable angina affecting left anterior descending coronary artery. 2- troponin T test , CK mb level and if given choivce coronary angiography 3- needs investigation and admission and follow him in ICU for at least 48 hours. Competing interests:   None declared
Acute Coronary Syndrome 26 April 2003
JYOTI RAMNIK PAREKH, G.P.Practitionar MUMBAI 400026 (INDIA) Send response to journal: Re: Acute Coronary Syndrome	a middle aged man ,smoker ,hypertensive, has sufficiant risk factors to suggest coronary artery disease. Competing interests:   None declared
It can be disscecting aneurysm of the Aorta 26 April 2003
Karthik M, resident India Send response to journal: Re: It can be disscecting aneurysm of the Aorta	The symptoms are pointing more towards aortic Disscection. The investigation :1. Colour doppler/USG 2. echo Treatment: Morphine for pain. Surgery Competing interests:   None declared
Aortic dissection in a hypertensive patient 26 April 2003
Joanna N Tenkorang, clinical/research fellow, cardiology Charing Cross hospital, W6 Send response to journal: Re: Aortic dissection in a hypertensive patient	This man has been hypertensive for two years. His pain is retrosternal, radiates to his back, does not respond to Proton Pump Inhibitors or muscle relaxants, there is no concrete sign of an acute Myocardial Infarct despite 2 days of pain, his history is not typical of pulmonary embolism, and an acute abdomen presenting as chest pain is unlikely given his normal haemodynamics and temperature. The most likely explanation must be impending aortic dissection. He ought to have a Chest radiograph, then transthoracic/transoesophagel echocardiogram, and /or CT of thorax. His wife should be told that investigations are being done to exclude a potentially serious condition (but which is treatable when diagnosed), and the possibility of surgery should be addressed. Competing interests:   None declared
aortic dissection until proven otherwise 26 April 2003
M D Dominic Bell, Consultant in Intensive Care/Anaesthesia The General Infirmary at Leeds LS1 3EX Send response to journal: Re: aortic dissection until proven otherwise	This patient's age, history of heavy smoking and hypertension, the refractory nature of the pain radiating through to the back, his observations on presentation and lack of evidence for any other specific pathology, cumulatively indicate the need to exclude an aortic dissection in the first instance. Plain chest x-ray should be followed by thoracic CT and/or angiography. Whilst appropriate to carry out cardiac enzyme studies, these should be complemented by full blood count, coagulation studies, base-line renal status and pancreatic enzymes. His wife should be told that although the diagnosis is not obvious at present, we need to exclude the possibility of a dissection of the aorta, the condition that affected Gerard Houllier, which would require prompt specialist attention for the best possible outcome. Since his wife is a nurse and capable of previously recommending self-treatment, the condition and its significance will hopefully be understood. Competing interests:   None declared
CLOSE FOLLOW UP WILL HELP 26 April 2003
ANJANELU.S CHITTA, physician shar/india/524 124 Send response to journal: Re: CLOSE FOLLOW UP WILL HELP	Male sex,age [40plus],smoker,hypertensive[ all risk factors for ischaemic heart disease] presenting with chest discomfort radiating to back one should first exclude coronory artery disease.Though first ekg is non conntributory,serial ekgs should be taken over perod of next 24 hrs.Trop-t test, Thaliium scan & if required coronay angiography may show some light on the problem. Competing interests:   None declared
Treat as cardiac untill proven otherwise. 26 April 2003
Chris topher L. Larmour, Cardiac Nurse Specialist Milton Keynes Nhs Trust, Standing Way, Eagle Stone, Milton Keynes. Bucks. MK6 5 LD Send response to journal: Re: Treat as cardiac untill proven otherwise.	Editor, I feel I am going to enjoy the case progress and outcome over the next four weeks. Like most people who present to A&E departments with chest pain it is unusual for the diagnosis to be clear-cut. My initial concerns would be cardiac. I would like to know more about the history of this mans pain, length of duration of pain, associated symptoms etc. He has some risk factors for CHD, smoking and hypertension. My working diagnosis would be ACS, and I know that that is sometimes seen as an easy way out, but at this stage there is not enough evidence to classify it any further. Further investigations are dependent on the time frame we are looking at. In the A&E department, I would like Troponin I, blood glucose, lipids and a Chest x-ray. I would also like continuous 12 lead ECG monitoring, with ST segment trending analysis, or if not possible then at least 1/2 hourly ECG's for the first couple of hours. I would also like to see this gentleman’s previous ECG's if they where available, to compare. I would also like to ensure this man was pain free, so would go for the MONA ((Morphine, Oxygen, Nitrates and Aspirin) approach. I would like repeat ECG's at any time if he had any further episodes of pain. From his history he should be admitted, as for what next, this will depend on the initial investigations, but I would still like to investigate a cardiac cause, unless he was a STEMI. He would need serial ECG's and enzymes, an ETT at some point, but all this is getting ahead of my self. I would like to speak to his wife and himself at the same time, I would explain what are concerns where and what we where doing. I would like to give them both time to ask questions, and express any fears that they might have. Initially I would reassure them that the ECG did not show an AMI, however I would also stress that this is not 100%. I would also tell them that he needs to report any episodes of pain to the staff straight away. Competing interests:   None declared
Acute Chest Pain 26 April 2003
Padmakumar N Pillai, Senior House officer in Medicine Rochdale Infirmary , Send response to journal: Re: Acute Chest Pain	The History sounds more like unstable angina ,though the ECG does not show any acute ischaemic changes. it will be worth while investigating further for elevated cardiac enzymes (creatinine kinase,AST, LDH ) and also for troponin I since he had pain for 2 days before presentation.serial ECG's are also indicated at this stage. it is justified in telling his wife that Peter may be having an anginal pain ,but we will wait for the blood results before confirming the diagnosis. Competing interests:   None declared
Aortic dissection 26 April 2003
Bernardino Roca, attending Castellon 12004 Spain Send response to journal: Re: Aortic dissection	1 What is the most likely diagnosis? Aortic dissection 2 What further investigations would you suggest? Troponin and d-dimers would be of great help. Image studies (echo, MRI and/or CT) would also be necessary to rule out aortic dissection. 3 What should you tell his wife at this stage? I would explain her that serious illnesses were a reasonble possibility. Competing interests:   None declared
?mi,?acute pancreatitis,?pulmonary embolism 26 April 2003
krishna kumar jada, none N9OGQ Send response to journal: Re: ?mi,?acute pancreatitis,?pulmonary embolism	from the history and the given clinical data the first diagnosis that comes to the mind is an acute coronary event.with the observed ecg changes and history it could be a nonst elevation MI(more likely) or unstable angina. there fore the investigation to be done should include cardiac enzymes assay- trop t, cpkmb , echocardiogram, chest xray, lipid profile. though the other history like alcoholism, history of jaundice, etc have not been given i think, if it is not a coronary event then one should keep in mind the possibility of pulmonary embolism and acute pancreatitis, hence one could also take serum lipase,amylase and D- dimer into consideration when investigating this man. i have a doubt that if it is due to dissection of aorta will the bp be maintained at systolic 160 and the man not in shock as the man has been experiencing pain for 3 days. in the mean time i would like to tell his wife that he is most proabably having a acut coronary event, but would like to inform her about the other possibilities as well. Competing interests:   None declared
acute coronary syndrome 26 April 2003
Dr. S. Ranjan, Registrar in medicine Teaching hospital, kandy Send response to journal: Re: acute coronary syndrome	1 It is too eary to arrive at a diagnosis. The ECG is not definitive. 2. I would arrange for serial ECG recording at hourly intervals and ask for cardiac enzymes. 3. He needs further investigations Competing interests:   None declared
Treat as a precordialgia (angina) 26 April 2003
Vitor S Hipolito, DR BRAZIL 39400 Send response to journal: Re: Treat as a precordialgia (angina)	Possible diagnosis: unstable angina/aortic dissection/GERD Further tests: ECG, cardiac enzymes, thorax X Ray, ecocardiogram What to tell to his wife: he is a 42 yrs old hypertensive man, who needs to be carefully managed. Tell about possible riscs. ( sorry for the english ) Competing interests:   None declared
Suspect Disecting Aortic Aneurism 26 April 2003
Mark R Hambly, Pre-clinical medical student St George's Hospital, London, SW17 0RE Send response to journal: Re: Suspect Disecting Aortic Aneurism	Although other diagnoses cannot be ruled out, such as unstable angina or damage to the myocardium following MI, surely it is essential to rule out the possibility of dissecting aortic aneurism, as this could explain all the observed symptoms, including the tachycardia and hypertension in the renal arteries are already being occluded. Investigations: X-ray and CT/MRI to image the aorta. Duplex to assess renal artery flow. Cardiac enzymes Liver function tests and enzymes. Tell his wife (and him!) that although the diagnosis is not certain, and we are carrying out tests to rule out reach a diagnosis, it is possible that her husband has an aortic aneurism. If this is the case, then we might have to carry out an emergency operation to give structural support to it and restore noemal flow. Competing interests:   None declared
gastroesophageal reflux disease 26 April 2003
malik rehman abdul, resident in deptt of nephrology baqai medical university karachi pakistan Send response to journal: Re: gastroesophageal reflux disease	a; gastroesophageal reflux b; endoscopy c ; no need to be extremely concerned .we r invetigating the exact problem right now. we will let u knoww as soon as we know it. it is more like a gatroesophageal reflux disease. Competing interests:   None declared
acute miocaidium infarct 26 April 2003
rosio guerra, yhut navy hospital Send response to journal: Re: acute miocaidium infarct	It might be an acute isquemya or infarct of miocardium Competing interests:   None declared
treat as a case of dissecting aortic aneurysum 26 April 2003
DR.ZAKI HUSSAIN KHAN, pgy1 karachi . 75850 Send response to journal: Re: treat as a case of dissecting aortic aneurysum	dissecting aortic aneurysum 1.urgetnt echocardiograpy 2.cardiac enzymes tell about the pt what r u suspecting that is ascending aortic aneurysum. Competing interests:   INTERNAL MEDICINE
exlude worst 27 April 2003
Dragan Trivanovic, dr General hospital Pula, Negrijeva 6, 52100 Pula, Croatia Send response to journal: Re: exlude worst	1.Acute coronary syndrome to exclude (this is commonly post-stress angina egzacerbation of mid-aged male smoker) no sign of tachypnea for suspicion on pulmonary embolism 2.cardiac enzymes, ecg of additional posterior limbs, heart echogram for dissection of aorta treatment with low molecular heparin after coagulogram results 3.it is important to talk with his wife about last days and tell her that it is hard to say prognose right now. Competing interests:   None declared
is this aortic dissection 27 April 2003
ravindhar vodela, sho medicine the royal oldahm hospital ,oldham UK, OL1 2JH Send response to journal: Re: is this aortic dissection	h/o chest pain increasing in severity raditing to back not releived by proton pump inhibitors, muscle relaxant in a hypertensive requiring two antihypertensive medications, heavy smoker and on examination sweating ,tachycardic even though on beta blocker with equal blood pressure in both arms [normal difference of 10-15 systolic in both arms ] though no pulse deficit,but ecg shows some minor ST segment changes ,left axis deviation even though systemic examination being normal my 1. provisional diagnosis will be to exclude aortic dissection 2. to exclude coronary artery disease 3.esophageal tear 4.pancreatitis he needs CXR , serial ecgs , BP monitoring in both arms ,FBC ,Blood for group and save, cardiac enzymes, 2DECHO to look at the aortic root, pericardial sac and hypokinetic myocardium, if there is widening of mediastinum on CXR or pleural effusion proceed to spiral C.T. thorax and abdomen ,serum amylase. Competing interests:   general medicine
chest pain 27 April 2003
nico de paola, pediatric cardiologist st peter hospital roma Send response to journal: Re: chest pain	chest pain , treat as heart attack close observation, cardiac enzymes, repeat electrocardiogram, echocardiography, chest x rays to the wife: j dont know actually the diagnosis, same test shall be administered and then j hope to tell you the right response Competing interests:   None declared
Treat as Acute Coronary Syndome until proven otherwise 27 April 2003
Sanjay P Ramdany, Snr Cardiology Research Co-ordinator Barts & the London NHS Trust, Whitechapel, London, E1 1BB Send response to journal: Re: Treat as Acute Coronary Syndome until proven otherwise	Likely diagnosis: Acute coronary syndome until proven otherwise. Differential diagnosis of Aortic dissection need to be excluded. Further Investigations: Repeat the ECG in 30 minutes and re-assess. If ST is evolving, then thrombolysis is warranted. Treatment should include, pain relief with an opioid together with an anti-emetic, Aspirin 300 mgs if not already given, consider IV metoprol (5mg Iv) for the hypertension or titrate up the current beta blocker and ace inhibitor if there is room to do so. I would also add a statin for plaque stabilisation irrespective of the cholesterol level. Routine blood markers should be sent but a Troponin level should be requested urgently as his chest pain has been ongoing for over 48 hours for risk stratification purposes. If the result of the troponin is elevated (therefore at high risk), I would start him on Clopidogrel and he should have a coronary angiogram. On the other hand if his troponin is negative, I would repeat it again in 12 hours time, and if it is still negative, do a pre discharge Exercise stress test pre-discharge and evalutate accordingly. What to tell the wife? : I would explain to the wife all of the above and I will update her and her husband on the medical management in the light of new findings. I will stress that it is important for us to get the diagnosis right so that the correct treatment be administered quickly and efficiently. Competing interests:   None declared
Response 27 April 2003
William Parsonage, Cardiologist Brisbane, Aus Send response to journal: Re: Response	Read the question everyone. What is the MOST LIKELY diagnosis? Ischaemic chest pain IS the MOST LIKELY diagnosis. Sure it may not BE the diagnosis but it is undoubtedly the MOST LIKELY. Measuring blood pressure in both arms, CXR, transthoracic echo etc etc for dissection is a waste of time. Sure all these things have some sensitivity as tests but the negative predictive value of all of them is poor and makes them next to useless for what is a potentially rapidly fatal condition. If you really think this patient has dissection then you have to do CT thorax with contrast, TOE or MRI. Competing interests:   None declared
Acute coronary syndrome 27 April 2003
Alejandro S Kufert, ccccccccc Callao 1175. 4 B. Buenos Aires Argentina. Postcode 1023 Send response to journal: Re: Acute coronary syndrome	In my opinion an the most important diagnosis to considerate is an acute coronary syndrome. Other possible diagnosis are aortic dissection, pulmonary embolism, esophagic spasm, panic attack, etc Competing interests:   None declared
Aortic dissection 27 April 2003
seyed amin zamiri, general practitioner iran Send response to journal: Re: Aortic dissection	The most likely diagnosis is aortic dissection There is four guiding points : history of hypertention , radiating the pain to back , wide pulse pressure and nonspecific ECG findings. At the next step I wouid perform a CXR and a two-dimentional echocardiography. I would say to his wife that he has to be admitted to an ICU for monitoring hemodynamics and urine output. Competing interests:   None declared
Urgency MI 27 April 2003
Miguel FE Derijcke, G.P. B-9600 Ronse Send response to journal: Re: Urgency MI	Myocardial Infarction probably antero-lateral region without excluding pulmonar embolism ; GERD To the spouse ,I should confirm her in her diagnosis and explain that other eventualities have to be explored Competing interests:   None declared
Aortic dissection definitely can't be excluded 28 April 2003
Shuk Yi Annie Hui, Med 3 Student University of Hong Kong Send response to journal: Re: Aortic dissection definitely can't be excluded	DDx: Aortic dissection (thoracic aorta) AMI Unstable Angina Ix: Cardiac Emzymes CXR Echo Ergent OT Competing interests:   None declared
Dissecting Aortic Aneurysm must be Excluded 28 April 2003
Nathan P. Gottehrer, Emergency Medicine Physcian Genaral Health Fund ISRAEL Send response to journal: Re: Dissecting Aortic Aneurysm must be Excluded	1.Dissecting Aortic Aneurysm must be Excluded !!! Although the most likely diagnosis is acute coronary syndrome. 2. Urgent chest CT with contrast material,troponin and repeated ECG is the second step. 3. Do not worry he is in good hands and we will inform you any thing new. Competing interests:   None declared
Minor opinion 28 April 2003
Regina B Stroebele, none none Send response to journal: Re: Minor opinion	There will be some psychosomatic headache at Vienna, too, when it comes not only to solution of the medical problem, but this also considering lack of confidentiality of personal data of an emergency patient mentioned with name, age, profession and co-morbidity. Kind regards from Munich, Bavaria/Germany Competing interests:   None declared
Myocardial Sarcoidosis 28 April 2003
Michael D Innis, Director Medisets International Home 4575 Send response to journal: Re: Myocardial Sarcoidosis	DIAGNOSIS MYOCARDIAL SARCOIDOSIS complicated by a bout of Acute Pancreatitis. TESTS The combination of Hypercalcaemia. Hypercalciuria, Hyperuricaemia and Hypergammaglobulinaemia is virtually diagnostic. Other helpful investigations are 1.Cutaneous anergy test with Candida, and Tuberculin. 2. Biopsy of Lip Salivary Gland 3. Gallium Scan. 4. Angiotensin Converting Enzyme elevated 5. Because of the epigatric pain the Serum Amylase should be determined. ADVICE TO WIFE Consult a Respiratory Physician for treatment. Competing interests:   Author/Owner of Medisets International - Computer Assisted Diagnosis
Radiologist in the byline... 28 April 2003
Andrew G. Robinson, Resident Internal Medicine Vancouver General Hospital Send response to journal: Re: Radiologist in the byline...	Given the fact that one of the authors of this case is a radiologist, I feel more it is more unlikely now that this is a ACS, or if it is an ACS, then the CXR will also show a pulmonary nodule which will serve as the basis for next weeks case. Given the fact that we have a patient with chest pain radiating to the back, and the fact that we have a radiologist on the byline, I feel the most likely diagnosis is a descending thoracic aortic aneurysm (ie a type B aneurysm) - the fact that the BP is the same in both arms suggests that the dissection would be distal to the left subclavian artery. I find these cases extremely interesting, and really have the potential of being the future of continuing medical education, it is fun to see the responses from around the world, from urban and rural areas, and from academic and non-academic centres. Hopefully other free e- journals such as the CMAJ follow this lead. Competing interests:   None declared
Aortic dissection 28 April 2003
shujauddin khokhar, senior registrar sabah hospital po box2207safat kuwait Send response to journal: Re: Aortic dissection	This patient has risk factors ie hypertension and smoking. Despite two days of chest pain there are no marked ECG changes. Therefore we must think of an impending aortic dissection. An urgent chest X ray and echocardiography and if possible CT chest should be done. Cardiac markers will help us to rule out acute myocardial infarction. I would reassure his wife that he is in best place to be treated and about my future plan to reach final diagnosis. Competing interests:   None declared
TYPICAL OF CARDIAC ARRHYTHMIAS 28 April 2003
kumar R S bhamidimarri, SHO Medicine southport district general hospital, southport, PR8 6PN Send response to journal: Re: TYPICAL OF CARDIAC ARRHYTHMIAS	1]WPW SYNDROME with episodic re-entry tachycardia causing ischemic pain The ECG does show 2 types of "QRS" complexes one of the types has got short PR and upsloping QRS. The fact that a prabable tachycardia caused symptoms it is worth while to try exclude underlying ischemic heart disease and HOCM-hypertrophic obstructive cardiomyopathy as there is known association of HOCM with WPW. 2]Investigations: -cardiac enzymes -thyroid functions tests, phaechromocytoma screening[by non-imaging methods] -ECHO,TOE -24 hrs ecg -to try identify accessory conduction pathways 3]-get family history -inform patient of list of medications to avoid -to follow up patient with cardiologist out-patients Competing interests:   acute medicine
patient with AMI 28 April 2003
ariefiansyah -, medical students jakarta 00000, - Send response to journal: Re: patient with AMI	1. I think the most probable working diagnosis for this patient is acute myocardial infarction. With the differential diagnosis coronary heart disease, arteriosclerosis, hypertensive heart disease, pancreatitis. 2. The next investigations that we need are laboratory examinations, ECG, radiology. At laboratory investigations we can check this blood glucose, blood lipid and cholesterol, enzymes of the heart, or we can investigate with interventional radiology. 3. The things that we can talk to the the patient's wife is about the lifestyle of this patient's. He must reduce the cigarettes that he has smoked everyday. Competing interests:   None declared
Could it be pancreatitis? 29 April 2003
Hsu Phern Chong, Final Year Medical Student University of Birmingham Send response to journal: Re: Could it be pancreatitis?	1.What is the most likely diagnosis? This man initially experienced epigastric pain 2 nights prior to his presentation.In addition, the pain is now increasing in severity and radiating to his back, which could be an argument for acute pancreatitis. Pancreatitis has also been associated with the use of ACE-inhibitors. His blood pressure was elevated and equal in both arms, therefore suggesting that an aortic dissection is unlikely. His respiratory examination and sats are normal,therefore it is also unlikely to be a pulmonary embolism. 2.What further investigations would you suggest? serum amylase, if elevated consider plain abdominal X-ray or abdominal CT 3 What should you tell his wife at this stage? Reassurance:she did the right thing by bringing him into hospital, where he can be managed appropriately. The diagnosis is unclear at the moment, but further investigations are underway.Considering that she is a nurse, an explanation about what the differential diagnoses are would probably be useful. Competing interests:   None declared
the troubling case 29 April 2003
hernan combessies, BMJ hospital pintos azul - argentina Send response to journal: Re: the troubling case	The diagnosis to consider is: acute coronary syndrome, acute myocardial infarction; other diagnosis are: aortic dissection, panic attack 2: ECG, CXR, cardiac enzymes and Troponin-I, ecocardiogram Competing interests:   None declared
Managing Chest Pain 29 April 2003
Sheikh M Haq, Consultant Palliative Medicine Withybush Hospital SA61 2PZ Send response to journal: Re: Managing Chest Pain	Diagnosis: Unstable Angina Ix: Cardiac Enzymes Information to wife: I would tell her that this is likely to be cardiac ischaemia. Further tests and observation needed to establish diagnosis. Patient should remain in hospital with further ECGs if there is more chest pain. Competing interests:   None declared
Cardiac unless proven otherwise but HOW?? 29 April 2003
S BAJWA, UK Northants NN1 Send response to journal: Re: Cardiac unless proven otherwise but HOW??	1. I would treat as Acute coronary syndrome, although oesophageal cause is possible.(Poor R wave progression on ECG!) Risk factors: Male, Hypertension, smoker, on beta blokers but HR 90? compliance! He would be very unlucky to get Dissecting Aortic aneurism with stripping of coronaries and MI but a possibility. 2. Needs CXR,Lipids, glucose, serial ECGs and monitoring, Biochemical profile and CBC.I would argue for a CT aorta if CXR suspecious or on going pain with No ECG changes with radiologists. 3. I will explain all three possibilities as above. Competing interests:   ACUTE MEDICINE
Agatha Christie? 29 April 2003
Alistair Howitt, GP Warders Medical Centre,Tonbridge,Kent, TN9 1LA Send response to journal: Re: Agatha Christie?	Most Agatha Christie novels start with the finding of a body and an obvious perpetrator, who you know cannot have done it as there are another 200 pages in the book. So would the BMJ really give us a case of myocardial infarction/ACS as its too obvious and its also the first of three episodes? What clues do we have? Some one with a history suggestive of high risk for vascular disease, so if not the heart, what about the aorta? Like an Agatha Christe novel, there are lots of red herrings/potential clues, epigastric pain is difficult to confirm without examining the patient, some subtherapeutic/inappropriate therapeutic trials to exclude a GI or musculoskeletal cause, and WHY did he think the pain was musculoskeletal? As for investigations, another clue, no imaging information but one of the authors is a radiologist, so why not start with a CXR? Am I being flippant, or is this latching onto confounding factors and minimal clues to generate testable hypotheses are reflection of how we tackle difficult diagnostic problems? Competing interests:   None declared
Abdominal causes should be considered too. 29 April 2003
Deepak Kejariwal, Senior SHO University hospital of Hartlepool, TS24 9AH Send response to journal: Re: Abdominal causes should be considered too.	The most likely diagnosis is Acute coronary syndrome. The risk factors are 42 year male, heavy smoker and severe hypertension, needing two antihypertensives. Aortic dissection is another possibility. But also need to be considered is the possibility of Pancreatitis. He needs an urgent CXR, Trop T, BP measurement in both arms and bloods including amylase. His wife needs to be told that we don't know the diagnosis as yet, but he will need to stay in hospital and be observed. Competing interests:   None declared
Patient permitted his details to be published 29 April 2003
Marcus Müllner, Associate editor, BMJ Vienna General Hospital Send response to journal: Re: Patient permitted his details to be published	In reply to Dr Stroebele I must point out that the patient, Peter Hartl, certainly allowed all his details to be used for our interactive case report. It is BMJ policy to publish such information only if patients give written consent. Marcus Müllner Associate editor, BMJ Competing interests:   None declared
Aortic Dissection 29 April 2003
GAMAL ALFITORI, clinical attachment Respiratory Medicine, nsh stoke-on-trent Send response to journal: Re: Aortic Dissection	The character of pain is highly suggestive of small aortic dissection.The patient seems to have angina as well,but it is not the cause of this last attack of pain. Investigations: Chest x- ray,abdominal CT scan,serum amylase. He may also need a transesophageal echo. I would tell his wife about the differential diagnosis and the investigations needed. Competing interests:   None declared
chest pain - ANXIETY/POLTIMI? 30 April 2003
yahaya yusuf aniki, medical officer soath africa Send response to journal: Re: chest pain - ANXIETY/POLTIMI?	MORE HISTORY IS NEEDED - WHAT ARE THE AGGRAVATING AND RELEIVING FACTORS, ?OCCUPATIONAL HARZARD,?SOCIAL HARZARD ?EXPECTATION, ?CONCERNS,?FAMILY HISTORY,?BODY MASS INDEX,?DRUG USE ETC IWILL CONSIDER ANXIETY OR POLTIMI AS A CAUSE BUT INITIALLY,WILL INVESTIGATE FURTHER TO RULE OUT SERIOUS CAUSES.A NON CARDIAC CAUSE LIKE,RELUX EOSOPHAGITIS, DIFFUSE ESOPHAGEAL SPASM IS ALSO PROBABLE. PEAK FLOW EXPIRATORY RATE, CHEST X-RAR, CRADIAC ENZYMES/ISOENZYME EG TROPONIN WILL BE CONSIDERED. Wife will be calmed and it will be explained to her that the patient will be closely monitored with pain releived. And that further investigation will be done as necessary and progress will be communicated to her. Also sieze the opportunity to explore home/family situation and try to involve her in decision makings with the husband's consent. Competing interests:   None declared
thoracic dissection 30 April 2003
fergus joseph dignan, cmp smc,raf lyneham,wilts sn15 4pz Send response to journal: Re: thoracic dissection	The most likely diagnosis is a thoracic dissection of the aorta;needs CXR and CT scan of the mediastinum;his wife should be told that he has a potentially serious condition for which urgent surgery will almost certainly be needed if the diagnosis is confirmed. Competing interests:   None declared
WPW vs AORTIC DISSECTION 30 April 2003
KUMAR RS BHAMIDIMARRI, SHO MEDICINE, SOUTHPORT DG HOSPITAL PR8 6PN Send response to journal: Re: WPW vs AORTIC DISSECTION	1]WPW SYNDROME, AORTIC DISSECTION, ACS 2]24HOUR ECG, TEO, ECHO, CT CHEST 3]TELL WIFE AWAITING DIAGNOSIS Competing interests:   ACUTE MEDICINE
AS USUAL NOT SURE ABOUT THE DIAGNOSIS 30 April 2003
VATSALA S VARADHARAJAN, SHO CARDIOLOGY PRINCESS OF WALES HOSPITAL BRIDGEND WALES CF31 1RQ Send response to journal: Re: AS USUAL NOT SURE ABOUT THE DIAGNOSIS	DIGNOSIS: Acute Coronary Syndrome DIFFRENTIALS: Aortic Dissection,GORD,??Pancreatitis INVESTIGATIONS: Continous Cardiac Monitoring,BMS,Serial ECGS,Troponin,Lipid Profile,TFT,Amylase, FBC,U+E, Whould get the opinion of the registrar regarding organising for an urgent CT Thorax.There is no need for an OGD now. INFORMATION TO WIFE: Not sure about the diagnosis.but will inform her about the various possiblities.I will inform her that we are doing the needful at the moment and shall let her know regarding further management plans after a discussion with my senior collegues. Competing interests:   None declared
acute aortic dissection 30 April 2003
manfredo turcios, emergency room hospital escuela,blv.suyapa, tegucigalpa,honduras.c.a .zc 504 Send response to journal: Re: acute aortic dissection	the most likely diagnosis is acute aortic dissection.---further investigations.-thorax xray,torax computer tomography,assay against smooth muscle myosin heavy chain,angiography.---wife:what the diagnosis is and the prognosis will depent of investigations results. jama2002,287[17]:2262-2272.-dare abstract20028260.-eur heart j 2001 sept22[18]1642-81.-radiology 2000,jun 215[suppl]1-5.-chest 1998,114:793- 795.-jpn heart j 1999,sept40[5]527-34 Competing interests:   None declared
angina 30 April 2003
sadaf salahuddin, medical officer karachi Send response to journal: Re: angina	i think patient was suffering from prinz metas angina echo cardiogram and troponin t and other protein assays should be done to rule out myocardial infarction his wife should be advised to counsel him for bed rest sublingual nitroglycerine or sprays if refractory Competing interests:   coronary vessel disease
Acute Coronary syndrome 30 April 2003
Adel H Regaila, Internal Medicine Resident Jersey city medical center Send response to journal: Re: Acute Coronary syndrome	Based on clinical presentation together with the risk factors (Hypertension, smoking, sedentary life style) the patient most likely is suffering from acute coronary syndrome (unstable angina). The patient, based on his clinical picture and ECG findings will most probably need in hospital admission for further work up initial work up should consist of 1. Basic labs (Complete blood count, Basic metabolic profile) 2. 3 sets of cardiac injury profile 3. chest x ray 4. repititive ECG according to the progression of the condition. patient should also receive a chewable aspirin, nitroglycerin sublingual, B blocker IV, morphine for the pain together with oxygen. The patient's wife should be told that based on his risk factors her husband has a moderate to high possibility of an unstable coronary heart disease and that he will need further in hospital management and more investigations to elucidate the degree of coronary artery blockade and the effect on heart muscle viability. Competing interests:   None declared
It should be acute coronary syndrome 30 April 2003
Dr.M.Thirughnanam Muthukumarasamy, consultant cardiologist in apollo hospital chennai, India. Chennai, 600106 Send response to journal: Re: It should be acute coronary syndrome	Patient had previous history of Hypertension , smoking and his age also should be considered. I would ask the patient to under go Tn T and I, echocardiogram, observe the patient for further angina, ekg monitoring, nitroglycerine, aspirin, to rule out the possible causes for coronary obstruction to prepare for angiogram. Competing interests:   None declared
Aortic dissecting aneurysm 30 April 2003
Mauricio Mejia, 3104786154 calle 105 Nº 14-140, 1, Pereira, Colombia, SouthAmerica, none Send response to journal: Re: Aortic dissecting aneurysm	He is most likely to be suffering an aortic dissecting aneurysm, because of the present risk factors of tobacco smoking and hypertension. Even so, you should search for an acute pancreatitis. I would order an urgent contrasted CAT Scan of the thoracoabdominal region, and some enzymatic tests (pancreatic amylases). The wife most know that the clinical status of her housband is delicate, and his condition could be life threatening. Competing interests:   Occupational Medicine Pharmacoepidemiology Toxicology
?PERICARDITIS 30 April 2003
JM Rumbold, staff grade private clinic B9 5PS Send response to journal: Re: ?PERICARDITIS	Acute pericarditis is possible:I would manage with non-steroidals and await cardiac troponins advising his wife appropriately Competing interests:   None declared
NON 30 April 2003
ZAMAN AMJAD, PHYSCIAN 11991, NON Send response to journal: Re: NON	HIST IS THAT OF AORTIC DISSECTION/PANCREATITIS BUT CLINICAL EXAM NOT IN FAVOUR.SO THIS PATIENT NEEDS I.C.U ADD AND FURTHER INV LIKE X.RAYS CHEST,SERIALS E.C.GS,TROP T/I S.AMYLASE,C.T THORAX/ABD IT CAN BE ACUTE CORONARY SYND. I WILL ASK HIS WIFE ABOUT THE DIFF DX AND TELL HER NEEDS FURTHER INV. Competing interests:   None declared
Unstable angina 1 May 2003
Dr.Juan Landaburu, Lima block 29.C 100 Lima 25-LIMA PERU Send response to journal: Re: Unstable angina	I think that the patient had a subepicardic ischaemia ,and it is necessary to apply ABCD from advanced cardiac life suport. And he needs to be in a coronary care unit. The last part of the EKG shows an elevation from the J point; it means an imminent infarction. Competing interests:   None declared
chest pain 1 May 2003
francis William Doyle, GP principal australia 3129 Send response to journal: Re: chest pain	urgent coronary angiogram Competing interests:   None declared
A 42 year old man with acute chest pain 1 May 2003
Marin Marinovic, ER Physician ER,Dubai,UAE Send response to journal: Re: A 42 year old man with acute chest pain	1.Dissecting thoracic anerysm 2.CXR followed by CT of the chest or even better TOE/transoesopahageal Echo/ 3.That the probable diagnosis or at least diagnosis that needs to be excluded is dissection of the thoracic aorta which is real emergency with high mortality if not treated quickly and effectively.Dear Madam,your husband needs urgent CT of the chest or TOE folowed by surgery in the nearest cardiothoracic hospital/if proven to be dissecting thoracic anerysm/.Even with succesful surgery morbidity and mortality may be significant. Competing interests:   None declared
peter hartl's condition 1 May 2003
Amin O Sharieff, resident saudi arabia po box 570 Send response to journal: Re: peter hartl's condition	1. inferior wall ischemia. It could also be Peptic ulcer,acute pansreatits or an abdominal aneurism.However his pfysical findings were normal.hence i would say the answer seems to be inferior wall ischemia 2.Helicobacter pylori stool antigen,serum gastrin,Cardiac enzymes.serum amyalse.and cxr abominal xray.serum cholestrol levels(long term management) 3.At this stage ma'am its hard to say,his symptoms are not specific to any one diagnosis.However i would advise an overnite hospital stay and Investigations so that we can know for sure.also in the long run,a healthier life-style is mandatory.He seems to have a sedentary job and is a heavy smoker.So these have to change. Competing interests:   None declared
Rule out pancreatitis and aortic dissection 1 May 2003
Carolina Acuña, Private institutions Buenos Aires Send response to journal: Re: Rule out pancreatitis and aortic dissection	I would draw blood for routine tests plus pancreatic enzymes and would ask for an enhanced scanner of the chest to rule out both pulmonary involvement a nd thoracic aortic dissection. Competing interests:   None declared
Acute chest pain 1 May 2003
Jose E. Roel, Anchorena 1407, 9º D, Buenos Aires, Argentina idem Send response to journal: Re: Acute chest pain	In this young, hypertensive man with severe acute chest pain radiating to the back, I would try to diagnose a dissecting aortic aneurysm. I would request a chest computed tomography. I would tell his wife that I am concerned about his pain and trying to check different diagnosis. Competing interests:   None declared
GP commentator's response 1 May 2003
Alistair J Howitt, GP Principal Warders Medical Centre, Tonbridge, TN10 4NJ Send response to journal: Re: GP commentator's response	The initial problem with giving a primary care perspective to this case is lack of any mention of primary care involvement in the evolving story, with the first medical contact being in the emergency department. Most of the respondents also work in secondary care, so I asked other doctors in my own practice and also members of the local GP vocational training scheme how they would respond. They quickly arrived at the same answers as those already posted, most likely diagnosis acute coronary syndrome, but need to consider dissecting aneurysm with the history of pain radiating to the back and the non diagnostic ECG findings. What did cause some discussion was the background to the presentation, for example, issues surrounding health care professionals treating their own family. Only two respondents, Mark Hambly, a medical student and Steve Goodacre mention discussing the problem with the patient. Peter's voice has been silent in this account. We do not know what his role was in the decision to delay presentation to a doctor for 48 hours, which could be potentially catastrophic in view of the differential diagnoses or to what extent he wishes to be know what is the matter with him and how involved he may want to be in any difficult decisions which may lie ahead, as he afterall is the patient. So in may be worth tactfully exploring these issues before deciding what to tell his wife. We might also gain some insight into her likely reaction on being told that so far the diagnosis remains uncertain. Competing interests:   I have been asked to be the GP commentator on this case.
R/O ACS then think about DES 2 May 2003
hoda kavosi, medical student,inturn tehran,021 Send response to journal: Re: R/O ACS then think about DES	Of course with only one ECG we cannot rule out ACUTE CORONARY SYNDROME, so we must observe patient. Also his HYPERTENSION needs more evaluation because in this age HYPERTENSION seems to be secondary. By all means I think he has DIFFUSE ESOPHAGEAL SPASM. of course he hasn't a good history and physical exam, even it hasn't respiratory rate. Competing interests:   None declared
42 yr old with unstable angina 2 May 2003
Alexander F Browne, house officer Nelson Hospital, New Zealand Send response to journal: Re: 42 yr old with unstable angina	I think the differential diagnoses in this patient are 1. Crescendo Angina 2. Pericarditis 3. Pneumonia secondary to the history of increasing chest pain, that sounds musculoskeletal, but a cardiac origin cannot be ruled out. Investigations: FBC, U&E's CRP, ESR and Troponin; given that he has had chest pain for 2 days previously a troponin may pin the diagnosis. A chest x-ray is indicated to help rule out chest infection. Inflammatory markers may help with diagnosing pericarditis. Management. The patient should be on oxygen and if he is still in pain some GTN sublingually. Enoxiparin (1mg per kg s.c.) is indicated for the treatment of acute coronary syndrome and should probably be given in this case. The patient should persist witht the B blocker in the mean time, an aspirin should be given to the patient acutely. Given his young age, hypertensive history and the fact that he smokes, early transfer to the cardiac unit for monitoring is indicated. Minor ST elevation in that ECG warrants further investigation, but thrombolysis is not indicated, especially without a comparitive ECG. Management of the wife. Tell her that cardiac cause for chest pain has to be excluded and so he is to be admitted to cardiology for further investigation. Encourage the patient give up the fags and encourage her to help him in this. Competing interests:   None declared
Acute Coronary Syndrome?!! 2 May 2003
Shabbar Bukhari, Intern Aga Khan University, Karachi, Pakistan. Send response to journal: Re: Acute Coronary Syndrome?!!	A1: The most likely diagnosis,I think, is Acute Coronary Syndrome (ACS). A2: I'd suggest Cardiac Enzymes. A3: I'd tell his wife not to panic..& that we are currently investigating him so as to rule out cardiac causes of his chest pain. Competing interests:   None declared
Emergency consultants response 3 May 2003
Harald Herkner, Consultant Department of Emergency Medicine, University of Vienna, Austria Send response to journal: Re: Emergency consultants response	At this stage most readers considered acute coronary syndrome (ACS), or aortic dissection, which are certainly the most significant diagnoses requiring immediate action. Pulmonary embolism was also mentioned frequently. This completes the collection of frequent serious causes of chest pain which have to be ruled out before other diagnoses are made. Reading between the lines suggests that Peter indeed presented in a critical condition. This is supported by findings e.g. profusely sweating without fever, heart rate 100 under beta blockers, increasing pain despite therapy, and suspected myocardial infarction by his wife, who is a healthcare professional. Emergency physicians frequently see critically ill patients walking into the emergency department. As reflected by the numerous responses suggesting ACS or aortic dissection, the likelihood of chest pain from severe causes is markedly higher in the emergency department setting than in a GP office. Considering pre-test probabilities of our patient presenting in the ED in an apparently ill condition we will like to act straight forward. Diagnostic workup naturally should start immediately, and should be as effective as possible, trying to kill two birds with one stone. Non-diagnostic ECG does unfortunately not rule out ACS. On the other hand ECG can make ACS very likely, or can reveal signs of right ventricular dysfunction if pulmonary embolism is present. Echocardiography may show aortic dissection or segmental wall motion abnormalities in ACS but also in aortic dissection, if aortic dissection involves the coronaries. In pulmonary embolism echocardiography may show signs of right ventricular dysfunction and pulmonary hypertension. Serum Troponins may be elevated in ACS, but also in pulmonary embolism. Serum D-dimer is elevated in pulmonary embolism, but may also be elevated in ACS and aortic dissection, which reflects its poor positive predictive value for each particular disease. A CT scan is a good means to diagnose aortic dissection or central pulmonary embolism. Due to different contrast and time settings one has to decide, whether pulmonary embolism or aortic dissection is the main diagnosis searched for. The remainder is left with a markedly reduced diagnostic power. Cardiac catheter is the gold standard for diagnosing and treating ACS, but it can also reveal aortic dissection. On the other hand, leading the catheter into the false lumen in aortic dissection may be deleterious.… . Often we have to choose diagnostic approaches upon availability, because critically ill patients do not only appear in the late morning when all resources are waiting to be employed. It is prudent to combine the tests in a time-economic way, e.g. draw blood, perform ECG and Echocardiography while the patient waits for the CT-scan. What to tell his wife? Most responses suggested to affirm her that we take the situation seriously and that diagnostic workup is necessary before details can be said. This is a very ‘professional’ answer to a healthcare professional, who has certainly given such an information very often. Nevertheless, I feel that signalling professionalism is one of the most important things at the beginning. I myself would like reassurance that my relatives are in good hands. Competing interests:   Emergency consultants response
the one diagnosis that should not be missed 3 May 2003
Samer A M Nashef, consultant cardiac surgeon Papworth Hospital, Cambridge CB3 8RE Send response to journal: Re: the one diagnosis that should not be missed	What is the most likely diagnosis? acute aortic dissection 2 What further investigations would you suggest? CT, MRI or TOE 3 What should you tell his wife at this stage? nothing until the investigations confirm or refute the presence of dissection Competing interests:   None declared
acue chest pain 3 May 2003
shyama rathore, gp E11 1BN Send response to journal: Re: acue chest pain	acute mycocardial infarction order cardiac enzymes would need to tell the wife the diagnosis of acute mycardaial infarction or acute coronary syndromes Competing interests:   None declared
Chest Pain 4 May 2003
Akanu abass Obasi, SHO-GU Medicine LGI Send response to journal: Re: Chest Pain	Chest pain of sudden onset lasting for up to three days not responding to simple analgesics in a heavy smoker and hypertensive. Patient also took (PPI)proton pump inhibitors without any relieve. slight ST elevations in ECG more on the chest leads. No abnormalities on abdominal and neurological examinations. Chest was clinically clear and no heart murmurs heard. Adequate analgesic will be given and further investigations will be carried out like blood investigations for cardiac enzymes, serial ECG monitoring to check for any heart attack (Myocardial infarction). Your husband will be admitted in the coronary care unit of the hospital for this management. Competing interests:   None declared
Aortic dissection in a hypertensive man 9 May 2003
Mohamad Abdelsalam Abdelkader, 8 may 2003 King Fahd Hofuf Hospital&31982 Send response to journal: Re: Aortic dissection in a hypertensive man	Aortic dissection in a hypertensive man is a stong possibility as there are no significant ECG changes suggestive of acute coronary syndrome.Also,gastro-oesophageal reflux disease GORD would be unlikely due to poor response to proton pump inhebitors. Competing interests:   None declared
response from rizgary hospital 9 May 2003
mothafar abdulrahman habib, consultant rizgary teaching hospital,Arbil,Iraq Send response to journal: Re: response from rizgary hospital	1.The most likely diagnosis is dissecting aneurysm of aorta. 2.Transesophageal echocardiography will confirm the above diagnosis. Competing interests:   None declared
Pancreatitis? 11 May 2003
Letterio Rizzo, Ortho Surgeon 98123 Messina - Italy Send response to journal: Re: Pancreatitis?	The thing is not clear. Anyway I would ask for cardiac enzymes, pancreatic enzymes and glycemia. Competing interests:   None declared
Obscure diagnosis w/symptoms presenting as chest pain 11 May 2003
Richard C Berglund, MD, Boneventure Medical Group Hoffman Est, IL 60195 Send response to journal: Re: Obscure diagnosis w/symptoms presenting as chest pain	1, Most likely diagnosis may not be the most apparent diagnosis. Without further investigational results known a working diferental diagnosis must include that which is most apparent and then progress to that which is less apparent. The present information (which is pared to the minimum) suggests acute non q-wave chest pain which may be based on coronary occlusive disease, but also may be a result of discecting thoracic aneurysm; other considerations would include esophagitis, PUD, cholecystitis, and/or pancreatitis. 2, Further investigations would include STAT CPK enzymes, troponin, D- dimer, cbc, metabolic panel. A CXR/PA&L should be obtained emergently as well as a spiral chest CT (if technology available). An abdominal CT should be obtained as well. 3, I would advise both patient and wife that more information is needed and will be obtained emergently. I would admit pt to a telemetry bed and obtain consultation with a cardiac surgeon. Competing interests:   None declared
not seem to be acute 15 May 2003
alparslan sahin, medical student gazi university school of medicine Send response to journal: Re: not seem to be acute	the patient has retrosternal pain as in the history of patient the pain wasn't relieved with the pills as he thought the pain could be related to gastrointestinal system or with muscoskeletal pain. i think this pain might be related with his hypertension . i would advise him to have an elective cardiology examination to rearrange his medicine and to take the treadmill test. Competing interests:   cardiology and emergency departments
Acute coronary syndrome 15 May 2003
Heong Keong Goh, Medical officer Malaysia Send response to journal: Re: Acute coronary syndrome	Since Peter has this retrosternal chest pain for the past 48 hours which is the first episode. I would consider acute coronary syndrome to be top in my list. He has underlying risk factors for iscahemic heart disease such as hypertension ,smoking, age and sex.I would rather look hard in there is any signs suggesting of dyslipidaemia in my physical examination. However, other possibilities of retrosternal chest pain should be considered here. One not to be missed is aortic dissection. Certainly they will present with high BP and sometimes with inequal pulses,oligouria or even lower limbs paralysis. This is less likely in the case because of his BP on presentation, his age and no obvious abnormal physical examination. However, aortic dissection is not uncommon in patients to present younger if they have some underlying diseases such as Ehler Danlos or Marfan's syndrome. There are a few important invesigations to be done urgently. Cardiac enzymes or if possible troponin level should be done urgently. Other baseline investigations should be done such as full blood count, lipid profile, electrolyte and clotting profile. Explanation to his wife is part of our management. She should be told about the diagnosis and clarified on the prognosis of the disease based on TIMI (Antman et al JAMA 2000) risk score.For Peter, I would say the prognosis is good. She should be explained also about the importance of risk modificition (eg stop smoking) after this acute event. Risk stratification would be done later to decide the neccesity of furthrt evaluations such as angiogram. Competing interests:   None declared
Chest pain 42 year old man 15 May 2003
Stephanie Mullings, pharmacist Hospital pharmacy N-1197 Send response to journal: Re: Chest pain 42 year old man	The man seems to be suffering from anemia,possibly megablastic anemia. Suggestion for The Schilling test to evaluate the serum folate and vitamin B12 levels. The wife should be adviced as to the dangers of self medicating and also that chest pains are serious signs of a heart condition. Competing interests:   None declared
Retrosternal pain-normal ECG 19 May 2003
Boudewijn J G G De Wilde, praktijk mariakerkelaan 270 8400 Oostende Send response to journal: Re: Retrosternal pain-normal ECG	-Lesion of LAD (new ECG after pain has disappeared) -Intervertebral disc lesion or dislocation of costotransversal joint of the corresponding segment. (examination of the vertebrae and thorax) -Rupturing aneurysm of the aorta (RX -echo) -Eusofagitis not yet responding to medication Competing interests:   None declared
EXCLUSION 21 May 2003
ashwaq alhadithi, sho in AE UK/HU13 0TD Send response to journal: Re: EXCLUSION	?PE. ?NON Q WAVE MI. ??PERICARDITIS. I WILL DO CXR,ABG,D-DIMER,WIEH THE FBC,BCP,CARDIAC ENZYME CRP&ESR. NEXT AND ACCORDING TO THE RESULTS V/Q SCAN. I WOULD TELL THE WIFE THAT WE STILL DO NOT KNOW FOR SURE THE CAUSE. WE WILL GIVE HIM ANALGESIA AND WE WILL WAIT FOR THE RESULTS OF THE OTHER TESTS TO COME BACK AND WILL TAKE IT FROM THERE. Competing interests:   None declared
Dissection of the thoracal aorta 23 May 2003
Oliver Lammel, Assistent Interne Departement DKH Schladming, 8970, Austria Send response to journal: Re: Dissection of the thoracal aorta	1.) Dissection of the thoracal aorta 2.) CXR, Echo, D-Dimer, Trop I (T) if neg. further investigations 3.) This kind of thoracal pain needs further investigation. So it is necessary to check up the husband. He has some risk factors, perhaps we have now the possibility to stop smoking, with her help. Competing interests:   None declared
acute aortic dissecying aneurysm 27 May 2003
anil maurya, staff grade reading Send response to journal: Re: acute aortic dissecying aneurysm	CT scan of Thorax Competing interests:   None declared
Re: Patient permitted his details to be published 3 June 2003
Hugh de Glanville, retired Weybridge, KT13 9EQ Send response to journal: Re: Re: Patient permitted his details to be published	That Peter Hartl allowed his name to be published in the series about his chest pain, as Marcus Müllner's reply confirms, is not in doubt. What is a little surprising is the consistently 'folksy' (or diminishing, according to how you view it) way he is subsequently referred to as 'Peter'. This new style for a BMJ case report seems, to me at least, akin to the indignity the old, and maybe the not so old, have to put up with in hospital these days of being called by their christian names by everyone from the cleaners upwards. Hugh de Glanville Competing interests:   None declared
Re: Re: Patient permitted his details to be published 27 June 2003
Beth Bennett, Sessional Lecturer & Clinical Educator Various/3000 Send response to journal: Re: Re: Re: Patient permitted his details to be published	That's "given names", not "christian [sic] names", the writer must mean. And surely the relevant consideration is what the person/patient wishes to be called: by her/his given name or addressed using her/his surname. Competing interests:   None declared
Response 24 November 2003
Suzete V. Mayo, generalist 1856, Treze de Maio str Brazil 01327002 Send response to journal: Re: Response	1)Acute Coronary Insufficiency. Differential diagnosis: oesophageal spasm, pulmonary embolism, acute perforated peptic ulcer, acute pancreatitis 2)Chest X ray, myocardiac enzymes, Echocardiogram Doppler Abdomenal Ultrasonography, Digestive Endoscopy 3)I will tell her that I dont know the diagnosis yet, and I will be more certain after the results of exams. Competing interests: None declared
IT IS DIFFICULT TO SAY AS NO SINGLE DIAGNOSTIC TEST TO CONCLUDE DIAGNOSIS 20 May 2004
Mohammed Azizuzzaman, SHO,Accident and Emergency Leicester royal Infirmary Send response to journal: Re: IT IS DIFFICULT TO SAY AS NO SINGLE DIAGNOSTIC TEST TO CONCLUDE DIAGNOSIS	Q 1. Top of my diagnoses :Acute Coronary Syndrome (Cardiac risk factor:Hypertention,Smoker) Other possible diagnoses :Aortic dissection ,Pericarditis,PE Q 2.Immediate Investigations :a)Routine bloods including cardiac enzymes,CK,CRP,WCC,D-dimers(CT PA if D-dimer high) b)Serial ECG c)CT to rule out aortic dissection d)Subsequent investigations :ECHO(to rule out pericarditis) ,ETT Q 3.We need to be honest to his wife regarding our uncertainness of our diagnosis at this stage.We can tell her our possible working diagnoses and further management plan. Competing interests: None declared
my opinion 28 February 2007
Laurentiu Iamandi, nephrology resident Internal Mediucine- Nephrology Fundeni Hospital- Bucharest Romania Send response to journal: Re: my opinion	1. History, the clinical examination and ECG does not let me be unflinching in sustaining the most likely diagnosis. There are few diagnosis that could be the right diagnosis: A.Acute Coronary Syndrome (heavy smoker, recurrent attacks of pain of a variable nature, sweating profusely, slightly elevated ST segments (0.1 mV) in leads I, aVL, V2, and V3,); B. Aortic dissection (history of hypertension,increasingly severe chest pain radiating to the back); C.acute pericarditis (slightly elevated ST segments (0.1 mV) in leads I, aVL, V2, and V3,); D.pulmonary embolism (ECG) 2. I think the most apropriate investigations are -cardiac ultrasonography that could exclude B and C and could show the left ventricular walls kinetics (A).US could show a right ventricular abnormality in D -Cardiac enzymes Competing interests: None declared