chest pain in 23 yo male

[erinto]

8/16/15-23 yo white male presented to UC with chest pain.    Was sent to the ED for further evaluation after getting 325 mg ASA.    He began feeling ill on Friday with generalized aches, chest pain and SOB.    Pain is not effected by movement or deep breaths, it is substernal, sharp, shooting, stabbing.   Does not radiate.   He rates it as a 7/10.   He feels worse with activities, relieved by rest.   He is usually very healthy.  He denies drug use, drinks socially, nonsmoker.   VS-88/39, 71, 9, 100 on RA.    Gait is unsteady, appears ill, heart S1S2, no M/R/G, Lungs are diminished, but clear, abdomen soft, nontender, positive BS, he has palpable pulses in all four extremities. 



Thoughts?    What orders would you put in?

[tyson]

The ekg looks very much like pericarditis. Diffuse st elevation. Pr depression. No signs of reciprocal changes. However, his vitals and hx worry me. I'd rule out a myocarditis. At least pop on trop and formal echo. I'd do serial ekgs. Could add on crp and esr as well. He's a def admit.

[erinto]

Excellent. Next set of VS-78/55,72,21,100. He was given two liters of NS wide open. WBC 14.9, hgb 14.3, hct 43, platelets 132, troponin 6.82, 69 segs, 19 bands. sodium 131, potassium 3.8, chloride 96, CO2-26, BUN-13, creatinine-0.96, glucose 116

Any guess on the troponin?





6.82!

He was transferred here from Bixby, admitted to CCU. The bed wasn't available, so he came to me. They did not do a CRP or sed rate. My very astute nurse/tech asked about URI symptoms. I added a strep and he was positive.

ECHO was normal. Developed bilateral pleural effusions, which were tapped, and normal. Blood cultures negative.
serial trops were 6.82, 15.88, 18.73, 11.68 (8/17 PM), then cardiology stopped checking.
He was sent home on antibiotics, 8/21/15, was doing well.

[erinto]

My only other comment on this, is that we often do not consider more than a CXR and EKG on young, healthy people. If you missed the elevations on him (Which granted, would be difficult), he could have had a very bad outcome. He was given NTG SL with a systolic pressure of 88. He dropped his pressure to 66/40, and should NOT have been given nitro, in my opinion. Nitro can drop pressures significantly, and I would not have given it in this hypotensive, ill appearing man. Luckily he responded to fluid resuscitation. He was never tachycardic, either, which is interesting, given his hypotension. Cardiogenic shock?