Under-diagnosed Chest Pain

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Quora Question: As a doctor, have you ever underdiagnosed a patient and what happened?

My Answer: Yes. And I'll answer like I was presenting the case during staffing.

A 51-year old White male presented to the ER with a six hour history of mid-sternal chest pain. He described it as a crushing pressure, non-radiating, constant, an eight on a scale of 1 to 10, and nothing he did made it better or worse.

His past medical history was significant only for peptic ulcers which were treated with ranitidine. His past surgical history was negative. Current medications included ranitidine and acetaminophen prn (as needed) for pain. The APAP provided no relief of his chest pain.

Family history was non-contributory. There was no history of sudden death in any close relative that he could remember. His father passed away at 76 from complications arising from a CVA (stroke), and his mother was still alive at 79. She had hypertension, glaucoma, anxiety, and dry macular degeneration but was otherwise in good health.

A physical exam showed a well-dressed, well-nourished, middle-aged White male, in some distress secondary to pain. Gait was normal and there were no gross neurological abnormalities. Skin was pale and diaphoretic. Sclera white, non-icteric (no jaundice), EOM-I (extraocular muscles) intact. Neck was supple, non-tender, and with a FROM (full range of motion). Lungs were CTA (clear to auscultation). Heart had a regular rate and rhythm, without murmurs or rubs. Abdomen was obese, non-tender, bowel sounds normoactive in all four quadrants, and non-tender to palpation. There was no HSM (hepatosplenomegaly, enlarged liver or spleen), or involuntary guarding. Calves were non-tender and there was no lower extremity edema. Genitourinary exam was deferred.

Based on his age, presentation, and PE findings, I was leaning heavily to an acute myocardial infarction (AMI) as the cause. So I ordered an EKG, chest x-ray, and labs that included a cardiac panel. All came back negative. What next?

I called the local internist and he suggested that I get a head CT. Why? He has chest pain, not a headache. The intern reassured me that in his experience, it was necessary. (Please be aware that some carriers will not cover this procedure if it comes back negative). So I did, but admitted him to the Cardiac Care Unit in the meantime because I was still sure it was a heart attack.

A couple of hours later, the results of the CT came back (those were in the days when we had mobile CT units). The scan showed a stroke in the thalamus, a structure in the forebrain which, along with many other functions, transmits sensory information to the cerebral cortex. In other words, the thalamic stroke made the patient feel like the problem was in his chest. I spoke with the doc on call for the hospital and told him the news. Since the patient was now his, he switched tactics. Thankfully none of my interventions worsened the cause. But then again, except for the oxygen I started him on, none helped, either.