Story of a Chest Pain Patient

So I had an interesting experience that I wanted to share. Scary for me actually, but it's a good teaching point.

Two nights ago my mom called me. I knew she'd been having some angina in the past week, off and on, and I (and everyone else) had been trying to get her to see a doctor, but good luck with that. So she calls me Thursday night and says "Last night I had jaw pain, and suddenly today I'm feeling nauseous and freezing and the chest pain is really increasing, it's lasting longer". When asked what the pain feels like she reported that it is a "pressure", a dull pain that is not severe, but definitely not comfortable (was impossible to get #/10). For some background, she's a 55y/o female with no significant family hx for any disease or disorder other than that her father died of colon cancer; she also takes a baby aspirin QD, and has not changed any medications recently.

Finally I convinced her that it was worth going at least to Urgent Care to get it figured out. Her boyfriend drove her, and by the time they got there he says she was faint and almost passed out. The Urgent Care providers did an EKG-- normal. But based on her sx they were very concerned of the possibility of an MI still, and sent her by ambulance to the hospital.

At the hospital they did another EKG-- normal again. Her vital signs were all normal except for temp which was 100.5 (barely even considered a temp). They drew blood for CPK and Troponin levels, and also took an x-ray. She had absolutely no other symptoms- negative GI, negative pulm, negative HEENT, etc. They also gave her pain medication because her chest pain was still intense.

So at this point I'm thinking MI, anxiety, flu, pulmonary embolism, pericarditis, etc, none of which seemed to fit exactly. So here's what I thought was the surprising part- she was diagnosed with lingular pneumonia. What?!?! Ok. So the lingula of the left lobe is just under the heart, and apparently when she pointed to where it hurt the doc said, "Yup, that's it". No real fever, no cough, nothing to signal pneumonia. But I thought it was an interesting teaching moment, at least for me, because it was so easy to think of heart and acute lung conditions immediately, and not spend enough time considering a broader differential. So when you can't figure out with a patient, think broader! Widen the diagnosis! Don't narrow it down too fast (this is something I have a problem with, so I really thought this experience taught me a good lesson)

And just so you know, they did an IV antibiotic drip (I was lucky to get the word "lingula" from my brother, definitely did not get the names of the medication), then sent her home with 5 days worth of Moxifloxacin, an inhaler, and pain medication (because the chest pain is still there). And she's doing a bit better now. Thank goodness for smart ER providers!