Need help from smart doctor

left pectoral pain is commonly associated with angina pectoris which is due to a insufficient blood flow to the heart during exercise. The pain is from the heart but the pain fibers of the heart travel in the same nerve as the left arm so you get referred pain to this region. Normally this occurs in people with coronary artery disease which is a narrowing of the vessels in the heart which is what leads to insufficient blood flow to the heart (ie not enough oxygen is getting to the heart cells) and therefor the pain that is experenced. This person probobly doesn't have CAD but if the person doesn't breath enough the oxygen levels in the blood can decrease and the heart can't get enough oxygen and therefor you experience the same pain as in a heart attack. I am not a 100% sure about this but hopefully others agree with me.

 

I actually like the lactic acid theory better. The likelihod of someone that age getting chest pain and muscle pain due to coronary insufficiency is practically nil. Also, pain from cardiac causes is more typically substernal (midline) not left pectoral (although it can present this way.

 

I like the lactic acid theory as well. The severe pain is most likely a muscle cramp and I don't remember the exact mechanism for this so you'll have to look that one up.

 

</font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by Whisker Barrell Cortex:
<strong>I actually like the lactic acid theory better. The likelihod of someone that age getting chest pain and muscle pain due to coronary insufficiency is practically nil. Also, pain from cardiac causes is more typically substernal (midline) not left pectoral (although it can present this way.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">Chest pain in any athelete, is cause for that athelete to be witheld from sports participation until they can have a work-up?
Muscle spasm in a teenage athelete is a diagnosis of exclusion.
After a good history and physical you might learn that the ,most likely diagnosis is exercise induced asthma. But, in any athelete that feels dizzy, has palpitations, or chest pain while participating in their sport, a careful family history of sudden death needs to be elicited, and probably a baseline EKG, and possibly an echo ( all to exclude hypertrophic cardiomyopathy ) Another condition to be excluded is one of the LongQt syndromes, which can be picked up on a baseline EKG, and may lead to lethal tachyarrythmias during exercise.It is a tragedy, as well as a potential lawsuit bombshell for their physician. ( Can anybody say Hank Gathers?)

Chest pain in young atheletes at the beginning of the season is not uncommon. HOCM and LongQt are uncommon.(unlike asthma) Therefore a high index of suspicion is needed in order to prevent sudden death in youn atheletes. Bottom line, if a kid has chest pains, they do not play until they can get a good history and physical and some sort of work up.

 

This does not sound like "chest pain" at all. It sounds like an exertional angina of her pectoral/deltoid girdle with strenuous activity. You'd probably get an ECG for medical-legal reasons, but I think you start with nutritional & biomechanical issues before you look @ things like thoracic outlet obstruction of her subclavian artery (by her first rib) or skeletal muscle abnormalities which would be dx. on a biopsy.

 

Considering the history, I would think the fatigue and pain would be normal after starting a strenuous exercise program. As for the chest pain, it says the pain developed after the workout&#8230;how about a pulled/torn pectoralis? She is a swimmer and a pulled muscle would be my first thought, although the much more serious possible cardiac conditions should be explored as well.

 

Sounds like myasthenia gravis to me, actually. Easy fatigueability due to autoimmune antibodies against acetylcholine receptors, increasing weakness with even more exertion. Women in their twenties are often affected, and limb weakness tends to be proximal. I'll bet that this is it. I suppose it could always be something like polymyalgia rheumatica, polymyositis, or some other autoimmune problem that presents with proximal weakness.

The chest pain sounds musculoskeletal to me, not cardiac. Cardiac chest pain isn't going to be sharp usually. She's too young for cardiac problems anyway, unless she has something congenital or a cardiomyopathy.

 

</font><blockquote><font size="1" face="Verdana, Helvetica, sans-serif">quote:</font><hr /><font size="2" face="Verdana, Helvetica, sans-serif">Originally posted by 7ontheline:
<strong>Sounds like myasthenia gravis to me, actually. Easy fatigueability due to autoimmune antibodies against acetylcholine receptors, increasing weakness with even more exertion. Women in their twenties are often affected, and limb weakness tends to be proximal. I'll bet that this is it. I suppose it could always be something like polymyalgia rheumatica, polymyositis, or some other autoimmune problem that presents with proximal weakness.

The chest pain sounds musculoskeletal to me, not cardiac. Cardiac chest pain isn't going to be sharp usually. She's too young for cardiac problems anyway, unless she has something congenital or a cardiomyopathy.</strong></font><hr /></blockquote><font size="2" face="Verdana, Helvetica, sans-serif">An athelete " gasping for breath" more than the rest of the atheletes. Like I said, the kid probably has exercise induced asthma ( which also causes chest pain and tightness. ) I know this isn't as exciting as polymyalgia or pheochromocytoma, but this is very common, and if missed can cause significant morbidity ( and even mortality )
She needs a good history and physical.( from somebody that knows what they are doing and not playing doctor like this coach )
Strained muscles are easily diagnosed on a physical exam with point tenderness. Chest wall disorders like costochondritis the same. Pleuritic pain, worse on cough or deep inspiration and alsoeasy to pick up Myesthenia gravis fibromyalgia. Unless you have myocarditis and CHF, I doubt you will be gasping for breath and having chest pain. Actually, she would not be able to swim if the cardiac dysfunction was bad enough to cause pulmonary edema. And Every other weird syndrome common only in the USMLE step 2 are not that likely. As prev stated, if the H and P are not suggestive of costochondritis, or just soreness after beginning a new workout regime, and the exercise PRFR ( pre and post ) or the H and P not suggestive of asthma ( which they are ),then the things that will kill her , and cost you a lot of $$ need to be ruled out ( HOCM, LongQt ) and if she looks Marfanoid, aortic dissection.
Also, kids can get MI's. That's why the history of sudden death, or MI in first degree relatives less than age 50 is important. Hyperlipidemias are not that uncommon, and she might even be on oral contraception and a smoker ( short of breath !! )
My guess, make the kid do a PEFR prior to and after swimming some laps. You will most likely fing a reduction in PEFR after exercise, which will respond to a variety of pre-exercise medications. That coach also needs to be aware to take her serious when she gets short of breath. Remember that Northwestern athelete that died last year from status asthmaticus, after some summer drills. The coach and Northwestern are gonna pay big time for that one. Lawsuit city , baby!
remember, common things are common ( and easy to treat)
Now story pertinent to how I thought of the world as an MS2 :
A MS2 is rotating through the wardswith the chief of medicine, and presents a young woman FUO.
He finishes the presentation and the Chief asks him, Young man, what is your diagnosis?
Well, says the MS2, I think she has Zebra Fever
Zebra fever, says the chief. Why there hasn't been a case of Zebra fever in the USA in 20 years,
Well, says the student, I am pretty sure she has Zebra fever.
OK, says the chief, we will send a "serum zebra assay" to the CDC just to humor you, and if she has zebra fever, I will buy you dinner at the nicest restaurant in town. then he preceeds to ramble on about common things being common, and that the lady probably has a pneumonia or something easy.

6 weeks later, the chief gets a phone call from the CDC explaining that a serum zebra assay he sent previously is positive. Shocked , he summoned the student and says, Young man this is one brilliant piece of diagnostics. I owe you dinner. Please tell me, how did you ever figure out that the patient had zebra fever.

Well, says the student, it was simple. What else causes a fever?

Wonderkind : pedi ER dynamo and amateur heartbreaker <img border="0" alt="[Clappy]" title="" src="graemlins/clappy.gif" />

 

Hmm. . .I agree that asthma is certainly more likely than anything I offered up as a possibility, but I took a different view of the history than Smythe did. I was reading the question as if the patient was going to have something more "zebra-ish" than common. Common things ought to be diagnosed without too much trouble, hopefully. I understand that even simple diagnoses can be missed, but I think I was reading this as a boards type question. Obviously, if the question was phrased, "what is the most likely etiology?", something like asthma would clearly be high on the list. Unfortunately, the Step exams often like to hit buzzwords and test your more obscure knowledge rather than the basic stuff that you ought to (and probably do) know. So, when I saw something like the "great fatigue" and "chronic pain" I took it to mean symptoms that were out of proportion to what a simple diagnosis would provide. This is why you can never substitute for getting a good H&P directly. Seeing the patient and getting a sense for whether these were simple symptoms or symptoms that seemed strangely significant would clear this up.

 

Then again, maybe I don't know crap about medicine. This is why I'm going into ophthalmology. . . <img border="0" alt="[Laughy]" title="" src="graemlins/laughy.gif" />

 

Pompe's disease. Classic step 1 question.

 

POMPE'S DZ...This question appears almost verbatum in one of my step 1 study books.

 

I thought Pompes was much more serious than this and in the severe form could be fatal. I think you would need more history to be sure though and if it is an genetic enzyme deficiency, it would show up earlier as well. Don't they also have myoglobinuria and hepatomegaly? I can barely remember though so you may be right.

 

I agree. Pompe's usually leads to death at &lt; 2 years of age. I do think this is a glycogen storage disease. With the post-childhood onset and exercise induction, most likely McArdle's vs Tauri. Since a diet of increased carbs was recommended, I think the prof was looking for McArdle's. AntGod, what did your prof say?