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Practice Interactive case report

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;332:406

Rapid Response:

herds of zebras ...

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:
None declared

Competing interests: No competing interests

21 February 2006
Matthew L Grove
Consultant Rheumatologist
NE29 8NH