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Old 11-01-2011
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Question Chest Pain in a 21-year old

A 21-year-old man comes to the emergency department complaining of chest pain and tightness, and shortness of breath. A friend accompanying him explains that they were at a party when the friend noticed the man was clutching his chest. He was also noted to be pale, dyspneic, and diaphoretic. A medical record obtained from a recent emergency room visit for a broken toe states he has no medical problems, has no allergies, and takes no medications. He is active on the tennis and basketball teams at the local YMCA. His father had a myocardial infarction at age 60. His mother takes medication for hyperlipidemia and needs to take antibiotics before dental procedures because of a “problem with a heart valve.” The patient’s blood pressure is 185/105 mm Hg and pulse is 120/min. Oxygen saturation is normal on room air. Physical examination is unremarkable. Electrocardiogram shows acute ST-segment elevations in the anterolateral leads. His pupils are dilated. He is hostile and mumbling incoherently. Which of the following is the most likely explanation for these findings?
A. Cardiac contusion
B. Drug overdose
C. Pheochromocytoma
D. Plaque rupture
E. Valvular incompetence
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Old 11-02-2011
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drug overdose
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Old 11-02-2011
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B. Drug overdose
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Old 11-02-2011
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B. Drug overdose , Cocaine ??
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Old 11-02-2011
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The correct answer is B. The main differential diagnoses for ST-segment elevations on the electrocardiogram include: acute myocardial infarction, ventricular aneurysm, pericarditis, and normal variants (secondary to J-point elevation). In a young patient with a presentation similar to those described in patients having a myocardial infarction, a high index of suspicion for drugs of abuse should be entertained, particularly amphetamines and cocaine. These drugs can precipitate acute myocardial infarction in healthy patients secondary to coronary vasospasm. In this case, the patient had taken too many amphetamines at the party, which precipitated the current event.

A cardiac contusion (choice A) can also cause ST-segment abnormalities. However, the contusion is usually attributed to blunt trauma, which is absent in this case.

Headache, profuse sweating, palpitations, and apprehension, often with the sense of impending doom, are common in patients with a pheochromocytoma (choice C). The blood pressure is elevated, often to alarming levels, and the elevation is usually accompanied by tachycardia. The paroxysm may be precipitated by any activity that displaces the abdominal contents. Although anxiety may accompany the attacks, mental or psychological stress does not usually provoke a crisis.

Plaque rupture (choice D) is more characteristic in patients who have risk factors for coronary artery disease, which appear to be absent in this healthy, athletic man.

Valvular incompetence (choice E) changes the blood pressure. In patients with aortic regurgitation the pulse pressure is increased and the diastolic pressure is decreased. In mitral regurgitation the systolic blood pressure is decreased because of a decrease in stroke volume.
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