A man in his 5os drives himself to the emergency department with 10/10 crushing chest pain, nausea, and shortness of breath. He was clearly uncomfortable when he arrived. Why did he drive himself there? Well, he was going to call an ambulance, but he happened to be only a couple of blocks from the hospital and thought driving would be quicker.
Heart attack, right?
Well, the EKG showed LVH with minor repolarization abnormalities and the POC troponin was negative. No acute MI.
The patient got some nitroglycerin. The chest pain didn’t improve, but the patient became hypotensive. He got IV fluids.
ECHO tech comes in and does an ECHO. No wall motion abnormalities. Normal ejection fraction. Mild LVH. An essentially normal exam.
Labs returned and CBC and chem panel are normal. D dimer is significantly elevated. His blood pressure comes up so he gets IV morphine.
Pulmonary embolus, right?
Well, the CT scan showed no PE. And there wasn’t a dissection, either. But the CT scan did show some abnormality coming off the aorta that wasn’t present on ECHO. Different density than blood, so it wasn’t a dissection. We decided to admit the patient and do further testing.
Not so fast. The patient has an HMO and our hospital isn’t in network. His chest pain is better after receiving the medications, so he gets transferred 30 miles away to another hospital.
What was his final diagnosis?
We don’t know. Never got a follow up call.
That’s one of the downsides to emergency medicine. You don’t get to finalize workups as often as you’d like. Was it esophageal spasms, a cardiac tumor, or a sneaky circumflex lesion?
Most of the time you don’t get follow up until one of your colleagues comes up to you and says …
“Hey, remember that guy with the chest pain you saw last week?”
And you think to yourself “why didn’t I become a plumber?”
This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.