A 28 year old postpartum woman with right sided chest discomfort: case presentation
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7538.406 (Published 16 February 2006) Cite this as: BMJ 2006;332:406All rapid responses
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WHAT WOULD BE YOUR INITIAL MANAGEMENT OF MRS PATEL ?
I would take her history and presentation very seriously. She has
been having right sided chest pain for almost two months.Initially,this
could look like as musculosceletal problem but not any more.....
The history of Mrs Patel's presentation definitely points toward ischemic
type of the pain.It comes with exertion and limits her activity.She has
few coronary risk factors.She has Diabetes,she is overweight with BMI of
34.I would like to know her cholesterol level as well.
If I am allowed to make some assumption on the basis of her surname,she
may be from Indian subcontinent. It is very well known that population
from that part of the world does have higher risk of Coronary artery
disease and they do present at an earlier age.I have seen people from
Indian subcontinent presenting with AMI/Unstable Angina in their thirties.
Therefore, I would like to know few more details about Mrs Patel's family
history,specifically related to cardiac problems.Is there anyone in the
family with known heart problem especially at early age?
One potential but unlikely( at least from the history) differential
diagnosis is Pulmonary Embolus.Therefore I would like to examine her calfs
for possible swelling and DVT. I must admit this is unlikely as right
sided chest pain that she is describing does not sound pleuritic.
Further tests will prove, or rule that possibility out.
WHAT FURTHER INVESTIGATION WOULD YOU SUGGEST ?
FBC,LFT's, TSH,T4, Cholesterol profile,
CK,CK-MB, Troponin
D-Dimer
CXR
Is the any previous ECG to compare with current one ?
WHAT WOULD YOU TELL MRS PATEL AND HER FAMILY AT THIS STAGE?
Well, as I understand she is already in Emergency Department.It would
be nice to know the results of some above mentioned tests before making
final decision.
Even without this results this pain sounds very cardiac to myself.This is
ischemic type of the pain.
Her resting ECG is showing some intersting changes like poor R progression
and T wave inversion in V2 and V3. This changes should be looked in the
context of presenting history of this young lady.This should be enough for
quick call to friendly cardiologist and further discussion with him( of
course, after having available all necessary blood results,CXR and another
ECG).
I would suggest admission and further evaluation of her right sided chest
pain.I have seen enough diabetic patients who presented with right arm or
right sided chest pain which were caused by Unstable Angina or better saying ACSy. I
would suggest admission and further evaluation of what looks to be
ischemic chest pain.
Competing interests:
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Competing interests: No competing interests
Several quick thoughts:
Firstly, Mrs. Patel has developed Type 2 DM at the relatively tender
age of 25. Not sure how I can directly tie this in to her chest pain, but
it is worrying. At 28, she is still very young to develop ischaemic heart
disease (diabetes notwithstanding, particularly as it is well controlled)
and the atypical location of her pain (right chest wall) is also against
this.
Both Pulmonary embolism and pneumothorax seem implausible. She has
been symptomatic for two months, which is a rather long time to have had
either of these without improving or deteriorating to the point where the
diagnosis would be obvious. Furthermore, the pain is not pleuritic in
nature. The only obvious risk factor for PE is her pregnancy, which at
seven months ago is remote. However (MRCP hat firmly on!) she is still
referred to in the title of the case as being post-partum, so pregnancy is
probably part of the answer.
The ECG is the only solid clue, suggesting a degree of rightward
rotation of the transverse electrical axis - although the main QRS axis
remains normal. There is no sign of RV strain, and (assuming 10mm and 2mm
squares for ECG calibration and the standard 25mm/sec rate) at 84 bpm she
is not tachycardic; both of these (for what it's worth) against Pulmonary
embolism.
Common things being common, the GP is correct and this should just be
simple costochondritis with a slightly atypical ECG. MRCP hat jammed
firmly around my ears, I predict peripartum cardiomyopathy (in complete
defiance of the absolute lack of signs of cardiac failure).
I would like some basic bloods - FBC, U&E, LFT; an ESR (I'm a
rheumatologist after all), a CXR and an echocardiogram.
Competing interests:
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Competing interests: No competing interests
The first possible diagnosis I consider is pneumothorax because: -
Right sided chest pain increased by activity, - Cardiac electrical
rotation on the longitudinal axis.
I'd like to have a chest x-ray to confirm or exclude pneumothorax. If
chest x-ray is normal I'll consider pulmonary embolism and I'd like to
have an ELISA D-dimer. If D-dimer is increased it's necessary to have a
pulmonary V/Q scan. If V/Q scan is normal it's necessary to confirm or
exclude great vessels, parietal or mediastinal pathologies with a chest
CT.
Competing interests:
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Competing interests: No competing interests
From the information given there is no clue as to what is causing her
symptoms although angina remains a possibility.
The ECG grid does not correspond with the size of the QRS complexes.
I presume the heart rate is normal.
She needs further investigations. Blood tests (FBC, ESR, U&E, XDP,
LFT, TSH) and chest X-ray to assess heart size and mediastinum) and
transthoracic echocardiogram looking for pericardial effusion and to
assess right ventricle and aortic root. Depending on the results go on to
exercise ECG.
Competing interests:
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Competing interests: No competing interests
If Mrs Patel's Hba1c is being monitored, so presumably is her TSH
(thyroid stimulating hormone), yet she is on a sub-physiological dose of
Levothyroxine. My immediate thought (long shot I grant you!) is papillary
carcinoma of the thyroid with lung metastases.
Investigations: chest x-ray, and scanning of chest and thyroid.
Start NSAID for pain and if my most tentative diagnosis is confirmed
high dose Levothyroxine.
I would explain that it is unusual for such a low dose of thyroid
replacement to work adequately which suggests "there might be something
else going on" - hence the need for further tests.
Competing interests:
None declared
Competing interests: No competing interests
Postpartum Exertional chest pain?
List of Diagnoses to exclude:
1.Pulmonary embolus with right ventricular strain
2.Post partum cardiomyopathy
3.Systemic Lupus erythematosis
CXR,FBC, Clotting screen,U&E as a basic work up. Autoantibody screen,
Lupus anticoagulant screen, and an ECHO will hopefully give us more
information.
will look forward to further information in the coming weeks.
Competing interests:
None declared
Competing interests: No competing interests