A 68-Year-Old Woman With Chest Pain and Dyspnea

Craig A. Goolsby, MD; Erik D. Schraga, MD

Disclosures

May 09, 2017

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 68-year-old woman with diabetes mellitus presents to the emergency department (ED) with substernal chest pressure and progressive dyspnea that has lasted for 4 days. Her symptoms have gradually progressed to the point where she has significant dyspnea, even at rest; this prompted her decision to come to the ED.

On a couple of occasions, she has had associated palpitations with presyncopal symptoms that required her to stop and rest for several minutes. Her chest pressure has become constant over the past 2 hours. She describes it as moderate in intensity, nonradiating, nonpleuritic, and nonpositional.

She is usually a quite active person who walks 1-2 miles per day and works in her garden. She notes that these symptoms have slowed her down to the extent that she has trouble doing basic activities around the house. She has never had symptoms similar to these in the past and is quite concerned. Further review of her systems reveals no evidence of lower extremity edema, orthopnea, or paroxysmal nocturnal dyspnea.

In addition, she denies having any long-distance travel, recent surgery, or immobilization. Her medications include an oral hypoglycemic and an ACE inhibitor. Her family history is remarkable for diabetes, but no history of early coronary artery disease is noted.

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