Differential Diagnoses
The chief complaint of a 45-year-old MR is a two hour left lower and mid-chest pain radiating to the back. The initial differential diagnoses include:
Angina pectoris, unspecified (I20.9) is a frequent type of chest pain that is caused by reduced blood flow to the heart. This disease may be characterized by sudden chest pain that is caused by an artery spasm in 20% of patients and may last more than several minutes (di Fiore & Beltrame, 2013). This spasm may be explained by last night’s fight and possible alcohol intake.
Acute coronary syndrome (I24.9) is a condition associated with suddenly reduced blood flow to the heart and the growth of chest pain that may radiate to the back (Makki, Brennan, & Girotra, 2015). Still, symptoms of ACS depend on the age of a patient.
A strain of muscle and tendon of the front wall of the thorax (S29.011A), also known as pulled chest muscle, is a health problem that may result from the last fight night and the inability of the patient to remember what happened there. This non-cardiac chest pain may be caused by gastrointestinal and non-gastrointestinal problems (Park et al., 2014). Non-visible fight traumas may cause this chest pain.
Pathophysiology of Diagnoses
Pathophysiology of angina: mismatch between blood flow supply and oxygen demand to the heart leads to the narrowing of a coronary artery.
Pathophysiology of ACS: obstruction of the coronary artery that leads to the reduction of blood flow to the heart.
Pathophysiology of pulled chest muscle: injury, fall, or other trauma leads to a strained muscle that causes pain.
Specific History Questions
Angina: “Is the pain sharp or crushing?” or “Can you describe this pain?” – to get an idea of the pain’s quality and areas where it causes discomfort.
ACS: “Where does the pain radiate to?” or “Will you rate the pain?” – to clarify the location and development of the pain.
Pulled chest pain: “When were first symptoms of chest pain noticed?” or “Is pain localized?” – to clarify if the pain is of the musculoskeletal origin or not.
PE Components
Angina: attention to third heart sounds that may be caused by dysfunction of the heart;
ACS: palpation to identify if there are some edemas or other changes that prove the heart’s failure;
Pulled chest pain: palpation and observation to check if there are some injuries or damage that cause pain.
One Diagnosis Rationale
Strained muscles may bother the man after his fight last night in a bar. As he does not remember what happened there at all, he can hardly explain what damage he could actually get. His drug and alcohol history should be investigated. A full physical examination is required to clarify if any other damage occurred.
Diagnostic Recommendations
Despite the cause of chest pain, it is suggested to take several tests. X-ray, MRI, and ECG are the most frequent diagnostic recommendations for patients with chest pain (Cigna, 2017). Ultrasound may also help to understand the nature of pain.
Medication
Celecoxib 100 mg 12 hourly is recommended as a pain relief for the patient (Babarinde, Ismail, & Schellack, 2018).
Education
The patient should be informed that many problems caused by chest muscle strains may be treated at home. Therefore, education and understanding of possible health complications are integral to treatment. It is not enough to learn that rest and careful physical exercises should help in a short period of time. Chest pain may progress without any reason. As a result, it is suggested to report any change as soon as possible. Physical therapy and a healthy diet should help. Cooperation with a traumatologist and a radiologist is required to interpret recent health changes and possible complications. The next visit to a therapist is suggested in one week unless new symptoms or worsening are observed.
References
Babarinde, O., Ismail, H., & Schellack, N. (2018). An overview of the management of muscle pain and injuries. Professional Nursing Today, 22(1), 14-23.
Cigna. (2017). Cigna medical coverage policies – Radiology chest imaging. Web.
di Fiore, D.P., & Beltrame, J.F. (2013). Chest pain in patients with normal angiography: Could it be cardiac? International Journal of Evidence-Based Healthcare, 11(1), 56-68.
Makki, N., Brennan, T.M., & Girotra, S. (2015). Acute coronary syndrome. Journal of Intensive Care Medicine, 30(4), 186-200.
Park, S.W., Lee, H., Lee, H.J., Chung, H., Park, J.C., Shin, S.K., … Lee, Y.C. (2014). Esophageal mucosal mast cell infiltration and changes in segmental smooth muscle contraction in noncardiac chest pain. Diseases of the Esophagus, 28(6), 512-519.