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here's a pt i saw while out in the boonies doing more than i should probably have been allowed. i'm curious as to how you approach cc's of cp in young patients with no risk factors.

17 yo hispanic male presents to ED with 1 hour hx of sudden onset "stabbing, constant" left sided chest pain from the margin of his sternum ~t4-t6 extending into his left axilla. no tachypenia/tachycardia, O2 sat 99%. lungs BCTA, heart RRR no murmurs. breathing unlabored but deep breaths do aggrivate pain. all vitals nl. was playing video games at onset of pain which is rating at 7-8/10. pain not reproducable w/palpation. movement of extremeties/torso does not aggrivate pain. no trauma hx. ROS unremarkable for anything (including sx of respiratory infection). reports having drunk 1.5 2-liter bottles of mt. dew in hours preceding onset.

medical hx postive for mild asthma which is currently not being treated.

CXR nl.

did not get an ekg or work this up furthur. called it pluritic chest pain and tx'ed as such. (attending agreed, signed the chart and sent the kiddo home).

i'm wondering if you guys think an ekg would have been in order? my feeling was obviously no (as was my attendings) but the nurses would not shut up about wanting to get one. did we skip a simple and relatively inexpensive tests that we probably shouldn't have? if this kid walked into your ED instead of the 3 pt/day ED in the middle of nowhere would you have worked him up differently?

and more generally, how much do you let your index of suspicion down (in terms of cardiac origin) for chest pain in young people with no other risk factors? does chest pain = chest pain = chest pain w/ the same sx in a patient who is 15, 20, 25, or 30?

and i know it's kind of a general question, so sorry about that.

dave
 

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If the clinical history for any reason makes me decide to pull the trigger, the young patients get a CXR and EKG, and (usually) stop there - unless, of course, there's something positive.

What are you considering in the young person? PE, PTX, anxiety, SVT, pericarditis, MSK pain - your film and EKG will cover these (well, not the anxiety or MSK - unless there's a fracture - but rules out the other things).
 

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Apollyon said:
If the clinical history for any reason makes me decide to pull the trigger, the young patients get a CXR and EKG, and (usually) stop there - unless, of course, there's something positive.
I agree with Apollyon. I get many CXR's and EKG's, without labs, on younger people with chest pain. Remember, it's not only an MI that you are looking for. An EKG is very helpful to rule out pericarditis in younger individuals.

Never forget, the young sometimes have MI's as well. A guy I went to college with was only 22, and already by then had suffered from 3 MI's... his first was at the age of 15. Although it's appropriate to screen these individuals for risk factors before going through the workup, it's also important to not simply blow them off.
 
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Um, I think I had this problem at 17 after 3 liters of soda. :scared:
 
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southerndoc said:
I agree with Apollyon. I get many CXR's and EKG's, without labs, on younger people with chest pain. Remember, it's not only an MI that you are looking for. An EKG is very helpful to rule out pericarditis in younger individuals.

Never forget, the young sometimes have MI's as well. A guy I went to college with was only 22, and already by then had suffered from 3 MI's... his first was at the age of 15. Although it's appropriate to screen these individuals for risk factors before going through the workup, it's also important to not simply blow them off.
ok, so i should have gotten the ekg. lesson learned.

just for my own education (since i'm still slogging away in the preclinical years) what are some of the sx's that would help distinguish pleuritic pain from pericarditis in a younger person? what are typical ekg findings in pericarditis that is not severe enough to cause tamponade?

and wow, three MI's by 22. did they guy have some unusual risk factors (familial hyperlipidemia or something)?

thanks for the education guys, i hope you know how much i appriciate having you all as a resource.

dave
 

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stoic said:
here's a pt i saw while out in the boonies doing more than i should probably have been allowed. i'm curious as to how you approach cc's of cp in young patients with no risk factors.

17 yo hispanic male presents to ED with 1 hour hx of sudden onset "stabbing, constant" left sided chest pain from the margin of his sternum ~t4-t6 extending into his left axilla. no tachypenia/tachycardia, O2 sat 99%. lungs BCTA, heart RRR no murmurs. breathing unlabored but deep breaths do aggrivate pain. all vitals nl. was playing video games at onset of pain which is rating at 7-8/10. pain not reproducable w/palpation. movement of extremeties/torso does not aggrivate pain. no trauma hx. ROS unremarkable for anything (including sx of respiratory infection). reports having drunk 1.5 2-liter bottles of mt. dew in hours preceding onset.

medical hx postive for mild asthma which is currently not being treated.

CXR nl.

did not get an ekg or work this up furthur. called it pluritic chest pain and tx'ed as such. (attending agreed, signed the chart and sent the kiddo home).

i'm wondering if you guys think an ekg would have been in order? my feeling was obviously no (as was my attendings) but the nurses would not shut up about wanting to get one. did we skip a simple and relatively inexpensive tests that we probably shouldn't have? if this kid walked into your ED instead of the 3 pt/day ED in the middle of nowhere would you have worked him up differently?

and more generally, how much do you let your index of suspicion down (in terms of cardiac origin) for chest pain in young people with no other risk factors? does chest pain = chest pain = chest pain w/ the same sx in a patient who is 15, 20, 25, or 30?

and i know it's kind of a general question, so sorry about that.

dave
I had a similar caucasian 19 yo male patient at a concert a few weeks ago. His CC was that it hurt to move and breathe. He had stabbing pain in about the same region of his chest and radiating up into the left shoulder area. Pain worsened upon breathing. It was a chronic problem for him and he had already received a 24 hr holter with no findings, but no other pmhx. No family history of cardiac problems or MIs < 65 yrs either. Lungs were also BCTA, all vitals normal. He said it didn't hurt as much by that point, but he was afraid he was going to drop dead on the concert floor. I ended up telling him we could call for transport to the ED if he wanted but he declined. I didn't see anything immediately wrong with him and told him just to return if the pain worsened, and continue to follow up with his family physician if the problem persists. Didn't seem likely to be an MI given the presentation, but I always feel a bit concerned when I have patients like this.
 

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stoic said:
what are some of the sx's that would help distinguish pleuritic pain from pericarditis in a younger person? what are typical ekg findings in pericarditis that is not severe enough to cause tamponade?
Here's a good overview of the electrocardiographic findings in pericarditis: http://www.aafp.org/afp/980215ap/marinell.html

I agree that a CXR and EKG are reasonable to do in this patient. That being said, it sounds like he has costochondritis, not pleurisy.
 

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Agree with the above posters for ekg and cxr. I am military and one of my two primary hospitals is where all the basic trainees in the air force come to if needed. CP is a multi-case per day headache. Most are MSK given that many are having to do pushups for the first time in their lives. Others are bull$h!t because they think we will be able to let them out of the military. (Wrong) Just last week though, we found a long QT and Brugata's. Needless to say, these kids will be going home. One with a defibrillator in his chest forever. History is everything in these kids, and unless there is a good one, I stop without drawing labs.
Steve
 

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I tend to concur here. You should do an EKG in young pts with chest pain. Don't want to send them out when they have undiagnosed WPW (even if your exam had nothing to do with it...). In general, its unusual but you want to make sure there aren't any major abnormlaties. Nl intervals, etc.

CXR to rule out fx and ptx

Plus or minus on Ddimer as a npp test

Def do a quick and focused cardiac history on these patients: FH, exertional/etc
 
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KentW said:
Here's a good overview of the electrocardiographic findings in pericarditis: http://www.aafp.org/afp/980215ap/marinell.html

I agree that a CXR and EKG are reasonable to do in this patient. That being said, it sounds like he has costochondritis, not pleurisy.
thanks for the link. i had a hard time making a case for costochondritis because this pain was absolutely not-reproducable by palpation or physical movement. only deep breathing. also no history of physical trauma (or activity at all really)

as a smidgen of evidence i present this quote from the emedicine article on costrochondritis: http://www.emedicine.com/EMERG/topic116.htm

"Pain with palpation of affected costochondral joints is a constant finding in costochondritis"
 

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stoic said:
"Pain with palpation of affected costochondral joints is a constant finding in costochondritis"
Whoops, sorry...I missed the word "not" in that part of the history ("pain not reproducible w/palpation.") :p

On a related note, here's a good article from the EM literature: http://www.emcreg.org/pdf/EMP0603.pdf

Specifically, it reminds us that chest wall tenderness may be present with serious underlying pathology, such as PE or ACS.
 

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Even though the pain was on the left side, the soda and the change in pain upon inhalation and exhalation seems like a cxr could have been done however having an ekg was a judgement call. for cya purposes i would have had him follow up with is fp within 3 days

and as far as further workups go, an ekg should be done before ordering more expensive labs
 
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igcgnerd said:
Even though the pain was on the left side, the soda and the change in pain upon inhalation and exhalation seems like a cxr could have been done however having an ekg was a judgement call. for cya purposes i would have had him follow up with is fp within 3 days

and as far as further workups go, an ekg should be done before ordering more expensive labs
we did do a cxr (it was nl). in my mind the big r/o was spontaneous pneumo, so that cooking before i even saw the kid.

as for follow-up, this was a rotation pretty different from what we're used to. 17 bed hospital run by 3 docs who also run the connected clinic and cover the ed. so he did follow up with his his pmd the next day, and that was us. he was feeling better with no sx within a few hours of coming in.
 
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I had a 22 year old patient, came in with just a smidge of chest pain. "Maybe" pleuritic. No DOE, no dyspnea now. He was training for a marathon and said it started as he leaned over to pick up a barbell. HR was 80s, normal VS. I did the basics, and added a D Dimer. D Dimer was 1900 (nml < 200). CTA showed a moderate sized PE.

I never on earth would have thought this gentleman would have had a decent sized PE, but the biggest risk factor for those with chest pain are... those that show in your ED with chest pain.

I think my gestalt picked up on the fact, that this was a well educated patient, with a normal affect and demeanor, good insight and judgement, and he still came into the ER for this chest pain... so something wasn't quite right.

Q
 

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DrQuinn said:
I had a 22 year old patient, came in with just a smidge of chest pain. "Maybe" pleuritic. No DOE, no dyspnea now. He was training for a marathon and said it started as he leaned over to pick up a barbell. HR was 80s, normal VS. I did the basics, and added a D Dimer. D Dimer was 1900 (nml < 200). CTA showed a moderate sized PE.

I never on earth would have thought this gentleman would have had a decent sized PE, but the biggest risk factor for those with chest pain are... those that show in your ED with chest pain.

I think my gestalt picked up on the fact, that this was a well educated patient, with a normal affect and demeanor, good insight and judgement, and he still came into the ER for this chest pain... so something wasn't quite right.

Q
Bravo Q!

Some rare causes of chest pain and sudden death in young athletes:

1. Hypertrophic cardiomyopathy
2. Anomalous coronary artery origin
3. Myocarditis
4. Myocardial bridging over coronary artery
5. Right ventricular dysplasia

1,3 and 5 have ECG findings sometimes associated. In 2 and 4 ECGs would be normal at rest but an exercise stress might bring out the ischemia.
 

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in my general day-to-day outpt peds setting, unless it is 100% reproducible by palpation or positioning they get an EKG. they're non-invasive, quick and (in my wolrd, not sure about civilian) cheap. you may catch the occasional weirdness, and if not, it's therapeutic for the more . . "sensitive" adolescents out there that may complain of every little ache and pain. don't forget to screen for drug use, either. they tend to piss the myocardium off as well. :)

--your friendly neighborhood adolescent exams = HA caveman
 

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I'm surprised that no one has mentioned precordial catch syndrome. It is common in adolescents and males, and can come on during episodes of rest (like playing video games). It is typically a pleuritic chest pain that is not reproducible with palpation, and it is entirely benign. The only thing that would be atypical for precordial catch for this case description would be the length of time that he was experiencing the pain. Generally, with precordial catch the pain last between 30 seconds and 3 minutes, but if this kid was having multiple episodes or was really freaked out by the initial episode that he felt he had to come in to the ED, then it fits. Here is the Wikepedia link: http://en.wikipedia.org/wiki/Precordial_catch_syndrome (not the greatest info on the subject, but the article that is referenced at the bottom is pretty good).
 

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j-snake said:
I'm surprised that no one has mentioned precordial catch syndrome. It is common in adolescents and males, and can come on during episodes of rest (like playing video games). It is typically a pleuritic chest pain that is not reproducible with palpation, and it is entirely benign. The only thing that would be atypical for precordial catch for this case description would be the length of time that he was experiencing the pain. Generally, with precordial catch the pain last between 30 seconds and 3 minutes, but if this kid was having multiple episodes or was really freaked out by the initial episode that he felt he had to come in to the ED, then it fits. Here is the Wikepedia link: http://en.wikipedia.org/wiki/Precordial_catch_syndrome (not the greatest info on the subject, but the article that is referenced at the bottom is pretty good).
Because when you hear hoofbeats, you don't automatically think zebras. Precordial catch syndrome is usually lower anterior chest pain, that is usually very lateral (almost to the nipple). The original description of the case patient's chest pain is that it was near sternal and radiated to the left axilla, which is not consistent with precordial catch syndrome.

Likewise, also arguing against precordial catch syndrome is the length of pain. This patient had pain for an hour, which is atypical of precordial catch syndrome (which normally is less than 3-5 minutes).

I think BKN raises some good points with his differential. I have to admit, I am not familiar with myocardial bridging over the coronary artery. BKN, mind explaining that one?

Also, one thing to consider is Prinzmetal's angina. I nearly activated the cath lab a few weeks ago for a 30 year old having substernal chest pain with acute ST elevations in the anterior leads (we're talking 4 mm here) with some mild reciprocal changes. The patient had a marked family history of CAD in males in his family in their 50's. One nitro and pain was completely relieved. As we were about to activate the lab, I got another EKG. COMPLETELY NORMAL. I got a cardiology consult (instead of activation), they took the patient to the lab a few hours later (electively), he developed ST elevation with the cath (which returned to baseline with NTG), and had completely normal coronaries.
 

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I would be looking for URI-type symptoms/history or at least some type of cough (even mild) with respect to the pleuritic CP idea...

but we just had a 30 y/o guy last week with chest pain, recent diagnosis and tx for severe tonsillitis... come back with positive CKMB and Troponins. His EKG was normal, his bedside echo was not impressive. But something didnt add up so the resident got enzymes... Go figure.

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southerndoc said:
I think BKN raises some good points with his differential. I have to admit, I am not familiar with myocardial bridging over the coronary artery. BKN, mind explaining that one?
i'm guessing this is a coronary artery with heart muscle spilling over the top of it. you get things beating really good and you can get some mechanical blockage/ischemia. i recall seeing a CTA of a heart in such a pt.
 

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stoic said:
i'm guessing this is a coronary artery with heart muscle spilling over the top of it. you get things beating really good and you can get some mechanical blockage/ischemia. i recall seeing a CTA of a heart in such a pt.
How would that give you mechanical blockage/ischemia? The coronary arteries are perfused during diastole, not systole.

If this is what he is talking about, then I do not see the association with ischemia. Maybe there is a predisposition to atherosclerosis, vasospasm, or some other disease? It certainly isn't uncommon to have coronary arteries within the myocardium. In fact, up to a third of the population has this.
 

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southerndoc said:
How would that give you mechanical blockage/ischemia? The coronary arteries are perfused during diastole, not systole.

If this is what he is talking about, then I do not see the association with ischemia. Maybe there is a predisposition to atherosclerosis, vasospasm, or some other disease? It certainly isn't uncommon to have coronary arteries within the myocardium. In fact, up to a third of the population has this.
This article may help: http://eurheartj.oxfordjournals.org/cgi/content/abstract/18/3/434

The mechanism appears to be a systolic reduction in coronary artery lumen diameter, with a delay in diastolic lumen gain, leading to ischemia in some patients.
 
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KentW said:
This article may help: http://eurheartj.oxfordjournals.org/cgi/content/abstract/18/3/434

The mechanism appears to be a systolic reduction in coronary artery lumen diameter, with a delay in diastolic lumen gain, leading to ischemia in some patients.
that's how it was explained to me. and i may be talking out my ass here, but it's my understanding that instead of being embedded in the mycardium, these patients often have a "normal" coronary that has an abberant ring of myocardium around it.
 
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stoic said:
that's how it was explained to me. and i may be talking out my ass here, but it's my understanding that instead of being embedded in the mycardium, these patients often have a "normal" coronary that has an abberant ring of myocardium around it.
Correct. I never knew there was a syndrome associated with it though. When I studied it in anatomy, I just thought it was normal in a third of people.
 

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southerndoc said:
Correct. I never knew there was a syndrome associated with it though. When I studied it in anatomy, I just thought it was normal in a third of people.
There was a rash of deaths in all-american and professional BB players in the 80s and 90s. Although crack seemed to be the numero uno, there was a lot of discussion of myocardial bridging and fibrosis or contraction band necrosis.

I see from one of the papers referred to in KentWs source that things continue to be unclear, but the theory has not died.

http://circ.ahajournals.org/cgi/content/full/106/20/2616

Excerpt : "The likelihood of ischemia also increases with the intramyocardial depth of the tunneled segment: In 22 of 39 hearts, myocardial fibrosis and contraction band necrosis were detectable in myocardium distal to the bridge.55 Among these subjects, 13 died suddenly and 6 during heavy exercise. These 13 tunneled segments were significantly deeper in the myocardium than the ones from the victims who did not die suddenly.55 "
 

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Interesting. I learned something new about a subject that I thought I knew. (Don't say that three times fast.)

When I learned this in anatomy, I just assumed it wasn't the cause of any disease. You know what they say: assumption is the mother of all [m]uckups.
 

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southerndoc said:
Also, one thing to consider is Prinzmetal's angina.
Just a noob question here, but would I be wrong in assuming Prinzmetal's can lead to an actual infarction in some cases? I heard of a 20 yo male who had chest pains, diaphoresis, etc., and his trops were really high. According to my friend the EP told him he had had an MI. He has no family hx of early heart attacks and no genetic diseases like familial hypercholesterolemia, so I have no idea what happened to him.
 

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Another pediatrician weighing in here. I agree with the above posters that the ECG and CXR are importent. If you're thinking MI in a kid, you should be thinking of a long list first. That being said, my friend who is an R3 at the local kids hospital admitted a 13 year-old with an MI and no family history. I saw an 18 year-old with chest pain and no other symptoms (no respiratory distress) who had an entirely collapsed left lung! Another thing -- don't forget the tox history: Coke, Crack and meth!

So think about the differential

Pneumothorax
Costocondritis
Precordial catch syndrome
Pneumonia
Pleuritis
Pericarditis
PE
Rib Fracture
Rib osteo (good case report recently in one of the peds throw away journals.
Asthma
Esoph foreign body
SVT
and of course MI

Any comments?

Ed
 

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leviathan said:
Just a noob question here, but would I be wrong in assuming Prinzmetal's can lead to an actual infarction in some cases? I heard of a 20 yo male who had chest pains, diaphoresis, etc., and his trops were really high. According to my friend the EP told him he had had an MI. He has no family hx of early heart attacks and no genetic diseases like familial hypercholesterolemia, so I have no idea what happened to him.
I'm guessing if it goes on long enough, you can have an actual infarction. It's coronary vasospasm so severe that it completely shuts off blood supply to the heart, so yes, it can cause an infarction. The ST elevation I saw in my patient was indication that there was myocardial injury.
 

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southerndoc said:
I'm guessing if it goes on long enough, you can have an actual infarction. It's coronary vasospasm so severe that it completely shuts off blood supply to the heart, so yes, it can cause an infarction. The ST elevation I saw in my patient was indication that there was myocardial injury.
I saw a guy at the Hop in the late 70s who said he had been admitted 170 times to various hospitals in Baltimore in 10 years for terrible chest pain, including two cardiac arrests in ambulance. He had had two clean coronary angios. For some reason he had never been to Hopkins prior to this visit. His pain was fairly resistant to NTG and Morphine and the story sounded very strange, so naturally we initially went to "drug seeker."

But, later we got the ambulance and hospital records, it seemed to be true.

When he had pain, his axis would change about 90 degrees and he would get minor ST changes (down not up).

This was early in the days of nuclear cardiology. We gave him some ergonovine and his anterior wall just disappearred. :scared: Then we gave him some NTG real quick. We called it prinzmetals and got him some nifedipine which was experimental at the time. Don't know if it helped him but it was all we had.
 

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southerndoc said:
I'm guessing if it goes on long enough, you can have an actual infarction. It's coronary vasospasm so severe that it completely shuts off blood supply to the heart, so yes, it can cause an infarction. The ST elevation I saw in my patient was indication that there was myocardial injury.
Sure can. Remember 2/3 have coronary lesions as well as vasospasm.
 

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BKN said:
Sure can. Remember 2/3 have coronary lesions as well as vasospasm.
I wonder if this "friend of a friend" did have a Prinzmetal's infarct instead of Prinzmetal's angina. I forgot to mention: his coronaries were squeaky clean, too, and he is apparently not a drug user.
 

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Odd to find this thread today...

Just admitted a 22yr old with major infarct this morning.

My prior record for the youngest was 17, but she had a major family hx.

ntubebate
 

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southerndoc said:
Because when you hear hoofbeats, you don't automatically think zebras. Precordial catch syndrome is usually lower anterior chest pain, that is usually very lateral (almost to the nipple). The original description of the case patient's chest pain is that it was near sternal and radiated to the left axilla, which is not consistent with precordial catch syndrome.

Likewise, also arguing against precordial catch syndrome is the length of pain. This patient had pain for an hour, which is atypical of precordial catch syndrome (which normally is less than 3-5 minutes).

I think BKN raises some good points with his differential. I have to admit, I am not familiar with myocardial bridging over the coronary artery. BKN, mind explaining that one?

Also, one thing to consider is Prinzmetal's angina. I nearly activated the cath lab a few weeks ago for a 30 year old having substernal chest pain with acute ST elevations in the anterior leads (we're talking 4 mm here) with some mild reciprocal changes. The patient had a marked family history of CAD in males in his family in their 50's. One nitro and pain was completely relieved. As we were about to activate the lab, I got another EKG. COMPLETELY NORMAL. I got a cardiology consult (instead of activation), they took the patient to the lab a few hours later (electively), he developed ST elevation with the cath (which returned to baseline with NTG), and had completely normal coronaries.

I don't think precordial catch is a zebra diagnosis. It is common, but underrecognized. I remember having similar symptoms myself when I was younger. I even came across this site with more info and what looks to be a support group at the bottom (no, I am not a member; though I do like the "purveyors of useless knowledge" subtext). http://www.failedsuccess.com/index.php?/weblog/comments/precordial_catch_syndrome_chest_pain/

You say that this case doesn't fit because the pain was "near sternal and radiated to the left axilla." I don't know how this particular teenager described his pain, but I think that I might report something along that line if I saw someone cupping the left side of his chest over his nipple (see the attached picture at the aforementioned site). I agree with you, the length of time argues against PCS, but I already mentioned in my previous post how the time factor may have been misconstrued. Factors in favor of PCS are that it is a stabbing, pleuritic pain in a young male with essentially no other worrisome symptoms (no tachy, diaphoresis), and the fact that it IS common.

Personally, I probably would still do the EKG because it is cheap and easy and it is possible that he could be having something much scarier as has been brought up by other posters. I just think precordial catch should still be pretty high on the differential.
 

ntubebate

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leviathan said:
What was the story behind the 22yo?
Came in with L arm numbness and profuse sweating. EKG looked like hell so she got a full siren salute on her way from my office to the hospital. Mom had an MI at 30 and dad died of massive MI at 46. Both grandparents on both sides passed from infarcts.

Currently also have a 23 year old with similar presentation who I am doing a CAD work up on, but he hasn't had an infarct.

ntubebate
 

southerndoc

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j-snake said:
You say that this case doesn't fit because the pain was "near sternal and radiated to the left axilla." I don't know how this particular teenager described his pain, but I think that I might report something along that line if I saw someone cupping the left side of his chest over his nipple (see the attached picture at the aforementioned site).

Personally, I probably would still do the EKG because it is cheap and easy and it is possible that he could be having something much scarier as has been brought up by other posters. I just think precordial catch should still be pretty high on the differential.
The patient did not complain of pain near the nipple. It was described by the original poster as parasternal, radiating to the left axilla. That is not characteristic of precordial catch syndrome. So I would put it much, much lower on my list of differentials. The rule of emergency medicine is to first rule out the things that can kill you, then rule out the things most likely to cause the pain, and then rule out the zebras. Precordial catch syndrome is probably as likely in this case as Mondor disease. If it doesn't quack like a duck, doesn't look like a duck, and doesn't walk like a duck, then chances are it's not a duck.
 
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ntubebate said:
Came in with L arm numbness and profuse sweating. EKG looked like hell so she got a full siren salute on her way from my office to the hospital. Mom had an MI at 30 and dad died of massive MI at 46. Both grandparents on both sides passed from infarcts.


ntubebate
aside from family hx, did she have other risk factors?
 

bulgethetwine

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CXR and EKG for definite. I would argue this is standard of care.

d-Dimer if suspicion is high, but if you didn't, I don't think you would be faulted for it. without a sat% anomaly.

I wouldn't even bother with the tox screen unless there were EKG abnormalities or vital sign derangement.
 
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