December 9, 2019

Left-sided Chest Pain – Family Medicine | Lecturio


So, in that same mode, let’s take a look again, chest pain. I love chest pain. I see a lot of chest pain. Healthy 40-year-old woman
complains of left-sided chest pain for the past eight weeks and it
bothers her about twice daily. Chest pain is a common
complaint in family medicine. And this is a younger woman, 40 years old. She’s had it for about eight weeks
and it’s very frequent, twice daily. So, let’s get some more
history and think about – think about this as we go through. The pain is sharp. It lasts seconds. It’s unrelated to exercise, but began after doing some
new moves in her yoga class. She feels a little tired, but otherwise her review of systems is negative. Think about what you would
include in that review of systems. And her exam is normal. She has a little tenderness to
palpation over her left lateral chest. And an electrocardiogram was done and shows normal sinus rhythm, no ST changes or T-wave inversion. Before we get to the answer, let’s breakdown her history
again for a second. Left-sided chest pain for eight weeks, it comes and goes. Of course, you have to think
about cardiovascular causes. You have to think about pulmonary causes. You have to think about musculoskeletal causes. The first thing is, I know she’s healthy and she’s 40. So, therefore, her risk index
should be fairly low. I don’t have a smoking history in here. I don’t have a family history. Those can be added in terms of
her cardiovascular risk assessment. It bothers her about twice daily. That doesn’t tell me much, but it is sharp and it last seconds. Tells me volumes. Angina, generally a dull ache,
not sharp, it lasts a few minutes, it doesn’t last seconds
and fleeting and goes away. Also, the pain is unrelated to exercise. Again, angina, often related to physical activity. And it started after doing some
new moves in her yoga class. What kind of moves? Because this is starting to
sound very musculoskeletal to me. She feels a little tired. That’s a concern. You can think about
some of the atypical diagnoses, such as pulmonary
embolism, for example. But a review of systems is negative. Could she have shortness of breath? Numbness and tingling? Nausea or vomiting? Those things, I’m sure,
are assessed. And her exam is normal. The fact that she has some tenderness, especially it’s in the same area of pain. We can’t reproduce the pain on palpation that’s present
in diagnoses such as angina or pulmonary embolism. But that said, most patients who have
chest pain deserve an electrocardiogram because she can, even with no risk factors, still have
some type of atypical presentation for angina. And therefore, it’s worth doing an EKG, which is a simple test
with a low rate of false positives and adverse events. So, the question becomes, what do we with this patient next? Do we refer her for her
treadmill stress test? Well, that’s not really accurate among women, correct? So, therefore, maybe you want
to go to the next step. If she has an atypical presentation, do better with stress imaging either with an echocardiogram or with nuclear imaging. Or do I think about
doing a left breast ultrasound. I didn’t mention breast pathology
could be a factor here too. But on the lateral side, in particular, yeah, it could be a cyst
or some other type of mass, even an abscess. Cancer, very unlikely to be painful. Or should it be reassurance
and simple analgesics? And I would go in this case for
reassurance and simple analgesics. And, of course, you can have your own opinions. This is just a limited case presentation. But based on everything here, it sounds like musculoskeletal
is going to be at the top of my list. And I’d like to see how she does
over time that this resolves. Certainly, a lot of warnings
about if the pain is changing, if it’s growing more severe, if the analgesics aren’t working, if she develops new symptoms, she’s going to be coming back to see you or calling or, if they’re severe, going to the emergency department. The chances of any of those
happening are very, very low. And this brings us to a nice clinical pearl. In the majority of chest pain
cases in the ambulatory setting and even in the emergency department are not related to acute cardiac ischemia. In fact, in primary care, it’s less than 5% of cases of chest pain
are related to acute cardiac ischemia. So, it is rare to see somebody
in active ischemia in your clinic. And so, certainly, it’s near – it has to be near differential. You’re going to assess those patients appropriately and even transfer the ones with high-risk conditions, but it starts with assessing the patient’s history. And for this patient, the key was really – it got worse after a move in her yoga class. So, there is a mechanism for, for example, a pectoral
strain which can produce her symptoms.

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