History – Demo

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Case 14

The patient was a middle-aged Caucasian man with a history of hypertension who was seen recently for extensive cardiac workup after complaints of chest discomfort. Work-up was negative. He complained the night before death of some possible chest tightness. He woke up in the morning, went to the bathroom, was observed to be short of breath and collapsed. Paramedics were called. The patient received advanced life support measures, including intubation, but died.


Next: External exam

Discussion Questions

1. What’s the differential diagnosis for sudden onset of shortness of breath followed by collapse (see history)?

2. What’s the differential diagnosis of the patient’s collapse based on the complete history?

3. How do you interpret the negative work-up after presenting recently with chest pain?

4. You are the treating provider. Your patient presents with a complaint of chest tightness. What do you include in your work-up?

5. You are the treating provider. Your patient with chest tightness has a “negative” work-up. What next steps would you take?


Case 14 – Educator Box 1

Case summary:
The case is good for considering the differential diagnosis and work-up of “chest tightness.” “Chest tightness or discomfort” was the patient’s symptom, but his recent (unspecified) cardiac work-up was negative and, at autopsy, his coronaries were general “clean.” The lesson for clinicians is to consider the importance of alternatives to coronary disease in this situation. Information not provided with the videos are the following: a heart weight of 540 grams (normal 400-450 grams); a left ventricular wall thickness of 1.6 cm (normal typically less than 1.2 cm). These findings fit for hypertensive heart disease.


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