Authors: Christopher Chung, Graham Johnson, Andrew Tabner / Editor: Steve Corry-Bass / Reviewer: Andrew Tabner, Christopher Chung / Codes: CP1, ResP1, SLO1 / Published: 13/11/2023
A 43-year-old woman presents to the emergency department (ED) with chest pain. She reports having pain in various parts of her chest/torso (under her left breast, the left posterior chest, left upper arm, lower back and hips) for a number of years. These pains have now become daily and persistent, precipitating her presentation to the ED. Initially the pain was intermittent and would occur both at rest and during exertion. She denies shortness of breath, sweatiness, clamminess or palpitations. She does not report cough, sputum, fever or weight loss.
The patient tells you that she emigrated from Sudan to the UK four years ago; her pain started a few months after her arrival in the UK.
She denies any past medical history and takes no regular medications. She is a non-smoker, doesn’t drink alcohol and has never been in employment.
On examination she is alert and appears comfortable at rest. She is overweight, of black African ethnicity and dressed in full-length sleeves and dress as well as hijab; she tells you she is a Muslim. Her chest is clear and her heart sounds normal. She has no oedema and her JVP is not elevated. There is no clinical evidence of DVT.
ECG: sinus rhythm, down going T waves V1 and V2, no evidence of ischaemia. Her troponin, d-dimer and chest X-ray are unremarkable.
25 responses
good for lateral thinking
More of a GP related case.
I disagree, a very common cause of presentation to the ED and easily addressed, can prevent recurrent attendances with chest and abdo pain
I agree patient should have attended GP with chronic nature of sx but they frequently don’t and come to us in ED! Knowledge of differential diagnosis and management is useful, even if just to re-direct pt to appropriate care and perhaps suggest f/u in letter to GP/practice nurse.
good and concise
Very Interesting Case
Learnt a lot from this case thank you
Really good one. Thanks !
very good -liked the NICE guideline it links to -the info on testing, diagnosing Vit D deficiency and differential diagnosis given here is really useful.
Good stuff for AE to be made were of. need confidence to tell patient to seek GP fu and review.
Excellent case
clear and concise.
very interesting case
Avery common condition which has been well highlighted by this interesting case.
Very interesting – worth thinking about this approach when patient have emigrated to UK or long term to UK
Easy to diagnose in this case history as led in right direction, bit more difficult in real life!
Interesting case!
I fully agree with most of the previous comments. This is easily one of the cases we could see in ED whether or not we think it is an appropriate attendance. Patients are often told by their GP (or the GP receptionist) to attend ED urgently if they only mention chest pain. It is very useful to learn more about possible differentials to cardiac/ pulmonary chest pain. It is a chance to shine if you can suggest to the GP to lurge into investigations for Vit D deficiency!
very common in my region, but not a lot of juniors think about it. The all over body pain is problematic, but being able to explain a potential diagnosis to people and how they can go about getting it treated usually makes the consultation go more smoothly……
learning point is atleast we know where the patient can go for help…..nice case.
Not often presenting to ed, but good to keep in mind as differential diagnosis
Good to know as a possible differential
I agree with previous comments. Although we should not see chronic aches and pains in ED, we frequently have to as patients are desperate to be seen and to get a diagnosis. Useful case
Good case
Another differential to consider