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February 2016: Chest

A 43-year-old male tool pusher reports to the clinic stating, “it feels like my heart is skipping beats.”  He first noticed it when he was home playing with his kids. The patient states it lasted for one or two days and then it resolved. This episode started 2 – 3 days ago, and he first noticed it when sitting at his desk drinking coffee. The episodes occur 3 times per day; they last approximately 10 – 15 minutes and spontaneously resolve.

He denies chest pain, shortness of breath, dizziness or headaches. He has been working 14 – 18 hr days preparing the rig for international travel.  He usually drinks 1 – 2 cups of coffee a day but he has noticed that lately he his consumption has increased to 1 – 2 pots of coffee per day. He is on day 6 of a 21-day hitch.

  • Past Medical History: Colon polyp removed at 39 – Benign, generalized anxiety disorder
  • Past Surgical History: Colonoscopy, appendectomy
  • Current Medications: Men’s multivitamin, herbal weight loss supplements, chromium picolonate, duloxetine HCl (Cymbalta) 60 mg/day
  • Allergies: NKDA
  • Immunization Status: Up to date including annual flu vaccine
  • Social History: Social drinker, smokes 2 packs a day
  • Family History: no known family history

Vitals

  • Temp 98.7
  • Pulse 88
  • Respiration 20
  • BP 156/89
  • POx 98% on Room Air
  • Weigh: 310 lb, BMI 45
  • Height: 5’10”

Physical Exam

  • General: A&Ox3, obese male, appears tired
  • HEENT: PERRLA, EOMI; TM’s appear normal, throat normal, sinuses are non-tender to palpation
  • Neck: soft and supple, trachea is midline
  • Cardio: regular rate and rhythm, no murmurs appreciated, but occasional extra beat appreciated
  • Lung: clear to auscultation bilaterally
  • Abdomen: soft non-tender, non-distended, normal bowel sounds
  • Extremities: no clubbing, cyanosis or edema, good peripheral pulses
  • Neuro: Grossly intact

Lab Work

  • Urine Analysis
    • Color – yellow
    • Clarity – clear
    • Specific gravity – 1.030
    • pH- 6.5
    • Glucose – negative
    • Bilirubin – negative
    • Blood – negative
    • Urobilinogen – 0.2 EU
    • Protein – 1+
    • Ketones – 10+
    • Nitrite – negative
    • Leukocyte esterase – negative
  • Troponin – negative
  • CKMB – negative
  • EKG

EKG Strip

How would you approach this patient?

Differential Diagnosis

  • Heart Attack
  • Heart Failure
  • Arrhythmia

Diagnosis: Arrhythmia

Treatment:

  • Monitor patient for 3-6 hours with cardiac monitor to capture episodes
  • Consider adjuvant therapy
    • Oxygen
    • Aspirin
  • Ensure patient comfort
  • Advise patient to avoid smoking and caffeine
  • CASEVAC

Discussion:

When dealing with patients with cardiac complaints, it is very important to first differentiate between life threatening events versus non-life threatening events. A patient with active chest pain and an abnormal EKG will most likely require an immediate medical evacuation. While this patient did not have a normal EKG, he was not actively experiencing chest pain and the available laboratory data indicated a non-emergent evacuation.

The EKG in this case showed a premature atrial contraction. While this is certainly a concern, the patient is not currently exhibiting any worrisome symptoms such as

  • Dizziness
  • Shortness of breath
  • Light headedness
  • Chest pain
  • Neck pain
  • General weakness

However, the etiology must be determined in order to address the symptoms. The patient has multiple risk factors that are of concern for coronary artery disease (CAD) including obesity, tobacco consumption and high caffeine consumption.

A family history is of great importance however in this patient’s case this information is not available. Therefore we should assume that he has family history of CAD given the prevalence of this disease in our society. The patient will require further evaluation by a specialist which may include a

  • 24 hr Holter monitor
  • Mobile cardiac telemetry
  • 30-day event recorder
  • 2-D echocardiogram
  • Stress test

If all testing is normal, avoidance of potential triggers such as cigarettes and high caffeine intake should be modified or avoid to prevent reoccurrence. The patient will be able to return to work once etiology of the arrhythmia has been confirmed and the symptoms are controlled and the patient must feel fully capable to complete his or her job functions.

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