Cardiology Case Challenge: Worsening Chest Pain After a Respiratory Infection in a Man With Hypertension

Abhimanyu Beri, MD; Fadi Abu-Yasin, MD


March 24, 2022

Physical Examination and Workup

Upon physical examination, the patient's pulse is regular, with a rate of 80 beats/min and good volume. His blood pressure is recorded at 130/80 mm Hg in the right arm and 134/77 mm Hg in the left arm. His oral temperature is 98.6°F (37°C).

Examination of the head, ears, eyes, nose, and throat is unremarkable, and no evidence of xanthelasma is noted. Neck examination shows the absence of jugular venous distention. Cardiovascular examination reveals normal S1 and S2 heart sounds, and no murmurs, gallops, or rubs are found. The chest examination shows good respiratory effort, with normal breath sounds and no splinting. The chest is not tender to palpation. The patient's abdomen is nontender and without palpable pulsatile masses. No indication of edema or erythema is seen in the patient's legs. The Homan sign is negative, and no venous cords are noted. The peripheral pulses are strong and symmetrical in all four extremities.

The laboratory evaluation shows a normal complete blood cell count and a normal basic metabolic panel. The creatine kinase level is slightly elevated, at 289 U/L (reference range, 0-200 U/L), with a creatine kinase-MB fraction of 3.9 ng/mL (reference range, 0-7.0 ng/mL) and an undetectable troponin I level (< 0.02 ng/mL). ECG is obtained (Figure 1).

Figure 1.

The initial management includes administration of aspirin, nasal oxygen, sublingual nitroglycerine, and morphine for pain control. Given his cardiac risk factors and presentation, the patient is admitted for observation to rule out an acute coronary syndrome. Serial cardiac enzyme measurements continue to be negative.


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