Physical Examination Findings in a Patient with Acute Chest Pain and EKG Changes

QUESTION

A 24-year-old male patient presents to the ER with an acute onset of chest pain that increases with inspiration and coughing. His EKG reveals diffuse ST segment elevation and PR depression. According to the most likely diagnosis of this patient, predict what you would expect to find on physical exam.

ANSWER

Physical Examination Findings in a Patient with Acute Chest Pain and EKG Changes

Introduction

Acute chest pain is a common and critical presentation in the emergency room, necessitating swift and accurate evaluation to determine the underlying cause. The combination of chest pain, diffuse ST segment elevation, and PR depression on an electrocardiogram (EKG) can raise suspicion for specific medical conditions. In this essay, we will explore the most likely diagnosis based on these EKG findings and predict the expected physical examination findings.

Likely Diagnosis

The EKG findings of diffuse ST segment elevation and PR depression in a young adult presenting with acute chest pain are suggestive of a condition known as acute pericarditis. Acute pericarditis is characterized by inflammation of the pericardium, the thin sac surrounding the heart. This condition is often associated with a sharp, pleuritic chest pain that worsens with inspiration and coughing, as seen in this patient.

Physical Examination Findings

When examining a patient with acute pericarditis, several physical findings may be expected:

Chest Pain: The hallmark of acute pericarditis is sharp, stabbing chest pain, which is often relieved by sitting up or leaning forward. The pain typically increases with deep inspiration and coughing, which distinguishes it from cardiac ischemic pain.

Pericardial Friction Rub: A characteristic finding in acute pericarditis is a pericardial friction rub, which is heard on auscultation. This friction rub is a scratching or grating sound and is best heard at the lower left sternal border during both systole and diastole. It may come and go but is typically persistent.

Fever: Patients with acute pericarditis may have a low-grade fever due to the inflammatory process.

Dyspnea: Some individuals may experience shortness of breath, especially when the pericarditis leads to pericardial effusion, which can restrict cardiac filling.

Tachycardia: A rapid heart rate (tachycardia) may be present due to the inflammatory response and discomfort.

Hypotension: In severe cases or if pericardial effusion compromises cardiac output, the patient may present with low blood pressure.

Other Signs of Inflammation: Signs such as elevated white blood cell count and an elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) levels may be evident in the laboratory findings.

Abdominal Pain: In some cases, acute pericarditis can radiate pain to the epigastrium or upper abdomen, mimicking gastrointestinal discomfort.

Conclusion

In a young adult with acute onset of chest pain, diffuse ST segment elevation, and PR depression on the EKG, acute pericarditis is the most likely diagnosis. A comprehensive physical examination should aim to confirm the clinical signs associated with this condition, such as chest pain, a pericardial friction rub, and other relevant findings. Proper evaluation and management are essential to address the underlying cause and provide relief to the patient, as well as to rule out other potential causes of chest pain.