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Clinical diseases should be comprehensively analyzed from the overall clinical data, avoid isolated and static view of certain symptoms and examination results, so as to avoid or reduce misdiagnosis and improve clinical comprehensive ability.
A while ago, the author encountered a case of "admission to the hospital due to chest pain, but the final diagnosis is not heart disease", sorted out here to learn with your colleagues, welcome to forward and share!
I. Case Profile
Male 64 years old, main complaint of "pain under the sword protrusion for more than 1 month, aggravated for 1 week". The patient suddenly appears at night under the blade of the knife, a dull pain of nature, with pain in the back, which is tolerated. Self-relieving after a duration of about 20 minutes. There was no obvious fever, no cough, no cough, no sweating, and he complained of frequent onsets of pain in the past week and was admitted to the hospital. The patient was previously in good health and the mother suffered from coronary heart disease.
Physical examination: body temperature 36.2 °C, heart rate 70 beats / min, pulse 18 times / min, blood pressure 135/65 mmHg. There is no yellow stain on the skin of the whole body, and there is no anemia. Low breath sounds at the base of both lungs, no distinct dry and wet rales, strong heart sounds, and no murmurs in the auscultation areas of the valves.
Second, the diagnosis and treatment process
■ 1. Laboratory tests in the hospital
Patients were admitted to the hospital to test for markers of myocardial injury: creatine kinase (CK), creatine kinase isoenzyme (CK-MB), and troponin I (TnI) without abnormalities. No abnormalities were found in liver and kidney function, coagulation function, and hematuria.
Table 1 Blood routine examination
■ 2. Other adjunctive tests
Figure 1 EcG: Sinus rhythm, ventricular rate 71 beats/min, early repolarization ECG
Fig. 2 Cardiac ultrasound results: widening of the aortic sinuses Mitral valve, tricuspid valve reflux (mild) left ventricular diastolic function changes
If the patient has new angina in the last 1 to 2 months (no history of angina or angina but has not had angina in the past six months, i.e., unstable angina), oral aspirin, metoprolol extended-release tablets, isosorbide mononitrate tablets, rabeprazole, atorvastatin are recommended, and hospitalization is recommended to improve coronary angiography, and revascularization is necessary. This is a patient often seen in cardiology clinics, and it is really simple to deal with.
However, this time things are really not so simple.
The patient complained of substabular pain again on the night of hospitalization, no dynamic changes in the ECG, no abnormalities in troponin, no abnormalities in CK 535U/L, CK-MB and lipase and amylase, and the blood routine was reviewed (see Table 2). After waking up in the morning, complaining of nausea and vomiting, the vomit is a yellow-green liquid, about 50-100mL, the symptoms are relieved after vomiting, and the pain under the sword process is better than before. But there was still pain, dull pain.
At this point, a typical sign comes to the doctor's attention — the patient has epigastric and subskeletal tenderness (+) and Murphy sign (+).
Under normal circumstances, patients with cardiac disease should not have signs of this acute abdomen, could it be acute cholecystitis?
Monitor the patient's temperature for fever, consider the possibility of acute abdomen, and give tramadol pain symptomatic therapy. The patient's pain was relieved after vomiting, and symptomatic treatment such as acid suppression and rehydration was given at the same time. The patient has a complete coronary angiogram.
Table 2 Review of blood routine results
Fig. 3 Coronary angiography results: no stenosis in the left trunk, no stenosis in the anterior descending branch and syringom branch, and irregular walls in the right coronary canal
The patient completes the abdominal ultrasound on the day after surgery: the abdominal gastrointestinal gas is obvious, the gallbladder volume is enlarged with tension, the hairs on the gallbladder wall are thickened (acute cholecystitis is considered), cholestasis is stasis, and the fluid periphery of the gallbladder is effusion (a small amount). Complete abdominal magnetic resonance cholepancreatography (MRCP) with the following results:
Figure 4 Abdominal MRCP results
For general surgical consultation, the patient is currently considering acute cholecystitis, fasting water, anti-inflammatory, acid suppressant and hydration, antispasmodic and analgesic therapy. Referred to the General Surgery Department for further diagnosis and treatment.
3. Summary
■ 1. There are several points to be done about the identification of cardiac symptoms:
Typical symptoms of angina are retrosternal (upper middle and upper sternum) that can spread to crushing pain, pressure, contraction, and suffocation in the precordial region. Radiates to the left shoulder, medial side of the left arm, up to the ring and little fingers of the left hand, and to the neck, pharynx, and jaw. Some people have angina attacks of chest pain and chest tightness are atypical, manifested as sore throat, jaw, upper limbs, neck and shoulders, back, epigastric pain, pharyngeal tightening (throat tightening), esophageal burning sensation, toothache, various types.
The elderly and women pay special attention to the fact that the elderly are more difficult to breathe, and diabetic patients do not even have clinical symptoms or only show chest tightness, that is, the so-called painless angina or even painless heart attack, which is called "atypical angina".
Compared with typical angina, atypical angina is more terrible and is often misdiagnosed as toothache, cervical spondylosis, acute cholecystitis, and pancreatitis. According to incomplete statistics, almost three out of every ten people have atypical angina, and many patients delay treatment.
In addition, the cause of angina pectoris is not necessarily coronary heart disease, the so-called angina generally refers to the coronary artery blood supply is insufficient caused. Clinically, aortic stenosis (angina, heart failure, syncope triad), aortic valve insufficiency (hypodistolic pressure due to inadequate coronary perfusion), pulmonary hypertension (right cardiac ischemia), and hypertrophic obstructive cardiomyopathy all present with symptoms of angina. At the same time, a small number of thymomas also have symptoms similar to angina pectoris, which require careful differentiation.
■ 2. How to identify cholecystitis from chest pain, so as to reduce misdiagnosis?
If the patient does not have the symptoms and signs of typical biliary disease, and angina with ECG changes, the patient should be asked in detail whether the patient is onset after a high-fat diet, whether the location of chest pain is clear, and the possibility of biliary heart syndrome and acute cholecystitis should be thought of when the treatment such as coronary expansion is ineffective. This suggests: the medical history must be detailed, the physical examination should be meticulous, and the atypical symptoms and signs should be highly valued.
Acute cholecystitis often has a history of biliary tract disease or repeated epigastric pain, and mostly occurs at night, after eating, lying flat and resting. Because the vagus nerve is excited at night, the gallbladder contracts to empty the bile; after a full meal, the bile is needed to digest food, the gallbladder also needs to contract, in order to drain the bile into the intestine, if the bile outflow channel is blocked by stones, the gallbladder will desperately contract, contract once, the pain will be aggravated, so paroxysmal pain or paroxysmal intensification.
Angina and myocardial infarction are mostly cold, emotional, and exerted.
Acute coronary syndrome in coronary heart disease is often accompanied by dynamic changes in troponin, myocardial enzymes, and electrocardiogram, and the mirror image of the central electrocardiogram is also helpful in diagnosing myocardial infarction.
Finally, remind the majority of colleagues that clinical diagnosis should not be "only seeing trees and not seeing the forest"!
bibliography:
[1] O’Reilly MV, Krauthamer MJ. “Cope’s sign” and reflex bradycardia in two patients with cholecystitis. Br Med J. 1971;2(5754):146.
[2] Papakonstantinou PE, Asimakopoulou NI, Kanoupakis E, et al. Cope’s sign and complete heart block in a 78-year-old patient with biliary colic. Int Emerg Nurs. 2018;37:3–5.
[3] Nishizaki M,Fujii H,Hiraoka M,Sakurada H,Yamawake N,Ashikaga T.ST-T wave changes in a patient complicated with vasospastic angina and Brugada syndrome: differential responses to acetylcholine in right and left coronary artery. [J]. Heart and vessels: An international journal,2008,23(3):201-205.
[4] Lau YM, Hui WM, Lau CP. Asystole complicating acalculous cholecystitis, the “Cope’s sign” revisited. Int J Cardiol. 2015;182:447–48.
This article was first published: Cardiovascular Channel of the Medical Profession
Author: Zhang Yunsheng Department of Cardiology, Airport Hospital, General Hospital of Tianjin Medical University
This article is reviewed: Zhao Jiehui
Editor-in-Charge: Yuan Xueqing, Zhang Li
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This article is original, reprint need to contact authorization
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