Assessment:

Problem List
1. Positional, pleuritic chest pain
2. Shortness of breath
3. Hypoxia
4. Tachycardia
5. Fever
6. Non-productive cough
7. Bilateral lower lobe crackles
8. Elevated JVP
9. S3
10. Bilateral LE 2+ pitting edema

The patient is a 22 year-old female who presents with a four-day history of aching, central chest
pain exacerbated by lying down, shortness of breath with activity, recent URI, and a remote
history of Hodgkins Lymphoma, of which she is in remission. The differential diagnosis for her
condition includes myocardial infarction, pneumonia, asthma exacerbation, pulmonary embolus,
sickle cell crisis, myocarditis, and pericarditis. Myocarditis is the MOST LIKELY explanation,
owing to the patient’s recent history of upper respiratory infection, fever, tachycardia, acute heart
failure, but does not sufficiently explain the positional and pleuritic nature of the patient’s chest
pain, which are more often seen in pericarditis. Likewise, pericarditis alone is insufficient to
explain the patient’s acute heart failure symptoms, but combined with myocarditis, all symptoms
are sufficiently accounted for. While MI could explain the patient’s acute heart failure and
associated symptoms, it does not explain her fever, and is unlikely owing to her young age.
Pneumonia, while explaining her hypoxia, fever, tachycardia and shortness of breath, is less
likely evidenced by her non-productive cough, bilateral crackles, and acute heart failure. Asthma
explains her hypoxia, shortness of breath, and tachycardia, but is less likely due to her “wet”
symptoms: dependent edema and elevated JVP. Pulmonary embolus explains the shortness of
breath and tachycardia, and could explain her acute R heart failure and associated systemic
venous backup, but is less likely due to the patient’s fever, and L heart failure symptoms, as well
as her lack of DVT symptoms or hemoptysis. Sickle cell crisis can be an explanation for the
patient’s chest pain, tachycardia, shortness of breath with hypoxia, heart failure, cough and
edema, but is made less likely due to the four-day duration of her illness, and the fact that the
patient has never been diagnosed with sickle cell trait.

Plan:

 EKG—r/o AMI; identify pericarditis (global STE)

 Echocardiogram—r/o structural abnormalities, wall hypokinesia, valvular complications;
estimate EF
 CXR—r/o structural abnormalities, lung consolidation vs. congestion; identify PNA
 CBC w Diff, D-dimer, troponin—rule out anemia, sickle cell, PE (low-risk Wells);
identify cardiac muscle breakdown
 Rx NSAIDs for pain