Skill Checkup: Man With a History of Type 2 Diabetes Complicated by Peripheral Neuropathy Presents With New Dyspnea

Alanna Morris, MD


January 27, 2022

Because of the patient's history, acute coronary syndrome is a key consideration. However, it is important to also consider other potential causes of this patient's chest pain, such as aortic dissection. In general, the pain of aortic dissection is distinguished from the pain of acute myocardial infarction by its abrupt onset and maximal severity at onset, though the presentations of the two conditions overlap to some extent and can be easily confused. An important clue in this case is the patient's blood pressure, which is nearly equal in both arms. Interarm systolic blood pressure disparity is a classic sign of acute aortic dissection.

Exertional dyspnea is the most common initial symptom in patients with aortic stenosis, even among those with normal left ventricular systolic function. It is frequently associated with abnormal left ventricular diastolic function. Patients may also develop exertional chest pain, effort dizziness or lightheadedness, easy fatigability, and progressive inability to exercise. Eventually, patients experience one of the classic triad of chest pain, heart failure, and syncope.

Most patients with myocarditis have a clinical history of acute decompensation of heart failure, which this patient does not have. In addition, they have no other underlying cardiac dysfunction or have low cardiac risk. Myocarditis is typically a presumptive diagnosis, based on patient demographics and the clinical course (eg, spontaneous recovery after supportive care).


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