chest pain

Pneumomediastinum, subcutaneous emphysema and pneumorrhachis following cocaine insufflation: a case report

Case Reports, Volume 19, Issue 3, Pages 113 – 172 (2020)

A case report on a 36-year-old male patient presenting to the emergency department (ED) with chest tightness, nasal sounding voice and subcutaneous emphysema 72 hours after the nasal insufflation of approximately 0.5g of cocaine. A plain radiograph of the chest demonstrated an extensive pneumomediastinum with subcutaneous emphysema extending into his neck. A computerised tomography (CT) scan confirmed the above findings, along with a pneumorrhachis of the thoracic spine. He was admitted locally for further investigation and observation.

Cocaine is the second most used illicit drug in the UK. The associated complications of cocaine can vary from acute coronary syndrome to acute psychosis. Pulmonological trauma secondary to cocaine misuse is commonly associated with inhalation of cocaine; we present this rare case of subcutaneous emphysema, pneumomediastinum and pneumorrhachis secondary to nasal insufflation. It is believed that deep nasal insufflation of cocaine is followed by forceful Valsalva manoeuvre, which allows for the rapid absorption of the drug and increases the euphoric effect. This forceful inhalation can lead to barotrauma and leakage of air into the posterior mediastinum.

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Non-Cardiac Chest Pain: management in the Ambulatory Clinic setting

Clinical Reviews, Volume 18, Issue 3, Pages 137 – 204 (2019)

Non-cardiac chest pain (NCCP) is a common presenting complaint which can be better managed. This requires the recognition of clinical sub-groups with investigation and treatment tailored accordingly. The aim of this paper is to encourage more accurate diagnoses and the better recognition of the source of chest pain. We discuss the appropriate investigations and management of each clinical sub-group.

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Dissecting the Diagnosis – An Unusual Case of Pericarditis

Case Reports, Volume 16, Issue 4, Pages 153 – 212 (2017)

Abstract

Chest pain is an extremely common presenting complaint on the acute medical unit. It is important to distinguish between patients who have serious pathology and those without. Often, the focus is on ruling out an acute coronary syndrome and inadequate consideration is given to other possible causes.

This case highlights the importance of performing relevant investigations in a timely manner, in order to ensure that a correct diagnosis is made.

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Problem based review: Pleuritic Chest Pain

Trainee Section, Volume 11, Issue 3, Pages 129 - 185 (2012)

Abstract

Pleuritic pain, a sharp discomfort near the chest wall exacerbated by inspiration is associated with a number of pathologies. Pulmonary embolus and infection are two common causes but diagnosis can often be challenging, both for experienced physicians and trainees. The underlying anatomy and pathophysiology of such pain and the most common aetiologies are presented. Clinical symptoms and signs that may arise alongside pleuritic pain are then discussed, followed by an introduction to the diagnostic tools such as the Wells’ score and current guidelines that can help to select the most appropriate investigation(s).

Management of pulmonary embolism and other common causes of pleuritic pain are also discussed and highlighted by a clinical vignette.

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ST-Segment Elevation in Patients With Cocaine Abuse and Chest Pain

Case Reports, Volume 13, Issue 2, Pages 53 - 100 (2014)

Abstract

Use of cocaine may complicate the diagnosis of myocardial infarction (MI) and may influence treatment strategy. Patients with symptoms suggestive of acute coronary syndrome (ACS) should be questioned about the use of cocaine. Initial management of cocaine users presenting with chest pain and ST segment elevation should include administration of glyceryl trinitrate (GTN). Assessment for resolution of chest discomfort and ECG changes should be undertaken before fibrinolytic therapy or angiography is considered. We present a case of patient with chest pain (CP) and ST elevation after cocaine use, whose symptoms and ST changes promptly resolved after medical therapy. Our case highlights the importance of medical therapy in patient with CP and ST elevation after cocaine abuse, before activating cardiac catheterization laboratory for emergent angiography.

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Chest pain and an abnormal chest X-ray – a case report

Case Reports, Volume 12, Issue 4, Pages 185 - 252 (2013)

Abstract

Chest pain is a common symptom amongst patients presenting to the acute medical unit, and presents a diagnostic challenge. We present the case of a previously healthy 65 year old year old gentleman with chest pain and subsequent vomiting, treated initially as an acute coronary syndrome, despite normal ECG and troponin. Chest radiograph revealed left basal consolidation with an effusion, suggesting pneumonia. The absence of symptoms of respiratory infection along with a normal C-reactive protein level led to further investigation with CT. This revealed evidence of oesophageal rupture (Boerhaave’s syndrome). Despite early surgical intervention our patient suffered a number of complications and continues his recovery in hospital three months post presentation.

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Exercise Stress Test Utility in Patients with Chest Pain Presumed to be of Cardiac Origin

Research Audit and Clinical Practice, Volume 12, Issue 3, Pages 125 - 184 (2013)

Abstract

Introduction: NICE stated exercise stress tests (EST) should not be used to diagnose obstructive coronary artery disease in patients presenting with chest pain presumed to be of cardiac origin.

Methods: A retrospective review of 209 patients with presumed cardiac chest pain was done. EST results, GRACE scores and need for invasive coronary angiogram (ICA) were analysed to predict the need for readmission, intervention and future events.

Results: The sensitivity of the EST in identifying obstructive coronary artery disease was 70%. The EST, ICA and the GRACE 6-month mortality had a 77%, 70% and 81% negative predictive value (NPV) for readmission respectively.

Conclusion: EST, GRACE scores and ICA are useful in providing prognostic information but are poor predictors of readmission. Follow up and education programmes are needed to reduce this burden.

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An unusual cause of ‘pleuritic’ chest pain

Case Reports, Volume 7, Issue 2, Pages 61 - 104 (2008)

A 77 year old man presented to A&E with sudden onset left sided chest pain. This chest pain was severe enough to wake him up from sleep in the early hours of the morning. The pain was pleuritic in nature and severe enough to require administration of intravenous morphine. He had a past medical history of ischaemic heart disease (1997), pulmonary embolism (1997), and left sided pnuemothorax (1998). Drug history consisted of lansoprazole 30mg od, isosorbide mononitrate 60mg od, nicorandil 10mg bd, aspirin 75mg od, beclomethasone 100 inhaler 1 puff bd, salbutamol 100 inhaler prn and combivent nebuliser qds. He was a retired miner, having worked for 40 years underground. There was also a 20 pack year smoking history although he had stopped for 20 years. He was independent and had a 100 to 200 yard exercise tolerance on the flat. Observations showed respiratory rate of 18, temperature of 36.5 degrees Celsius, BP 133/69, oxygen saturation of 98% on air and a regular pulse of 70 beats per minute. Clinical examination did not reveal any abnormality, with no abdominal or chest wall tenderness.

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Intra-Pericardial Rupture of Bacterial Hepatic Abscess: An Unusual Cause of ‘Cardiac’ Chest Pain

Case Reports, Volume 5, Issue 3, Pages 81 - 116 (2006)

Abstract

We report a rare case of bacterial pericarditis secondary to rupture of liver abscess into the pericardium. The patient presented with cardiac-sounding chest pain and with normal ECG, CXR and Troponin-I assay. The initial echocardiogram showed minimal pericardial fluid but, when he later developed overt clinical signs of cardiac tamponade, a CT scan of chest and abdomen revealed a pronounced pericardial effusion. It also revealed an abscess located in the left lobe of liver and this had apparently ruptured into the pericardial sac. Culture of the purulent pericardial aspirate grew Proteus and Enterococcus; these organisms have been reported only rarely as responsible for causing purulent pericarditis. The patient was treated initially by emergency ultrasound-guided pericardiocentesis; later he required thoracotomy and pericardiectomy in order to manage persistent re-accumulation of pus in the pericardium.

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