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Diagnostic conundrum

A man in his 5os drives himself to the emergency department with 10/10 crushing chest pain, nausea, and shortness of breath. He was clearly uncomfortable when he arrived. Why did he drive himself there? Well, he was going to call an ambulance, but he happened to be only a couple of blocks from the hospital and thought driving would be quicker.

Heart attack, right?
Well, the EKG showed LVH with minor repolarization abnormalities and the POC troponin was negative. No acute MI.

The patient got some nitroglycerin. The chest pain didn’t improve, but the patient became hypotensive. He got IV fluids.

ECHO tech comes in and does an ECHO. No wall motion abnormalities. Normal ejection fraction. Mild LVH. An essentially normal exam.

Labs returned and CBC and chem panel are normal. D dimer is significantly elevated. His blood pressure comes up so he gets IV morphine.

Pulmonary embolus, right?
Well, the CT scan showed no PE. And there wasn’t a dissection, either. But the CT scan did show some abnormality coming off the aorta that wasn’t present on ECHO. Different density than blood, so it wasn’t a dissection. We decided to admit the patient and do further testing.

Not so fast. The patient has an HMO and our hospital isn’t in network. His chest pain is better after receiving the medications, so he gets transferred 30 miles away to another hospital.

What was his final diagnosis?

We don’t know. Never got a follow up call.

That’s one of the downsides to emergency medicine. You don’t get to finalize workups as often as you’d like. Was it esophageal spasms, a cardiac tumor, or a sneaky circumflex lesion?

Most of the time you don’t get follow up until one of your colleagues comes up to you and says …

“Hey, remember that guy with the chest pain you saw last week?”

And you think to yourself “why didn’t I become a plumber?”

This and all posts about patients may be my experiences or may be submitted by readers for publication here. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.


  1. I agree that follow up after the patient leaves your office or facility is one of the most frustrating parts of medicine.

    If you do it long enough, you may see the same patients over and over. Or you may see the families, who will fill you in. This is only patchy, however.

    I am old enough to be seeing the babies I delivered as adult patients now. It’s a bit weird.

  2. The weird thing is it’s often the same with inpatients. Since my patient assignment changes almost every day, you’ll have this deep connection with them for 12 hours and then wonder whatever happened to them.

  3. Maybe call the patient under the auspices of seeing how they are doing? (something we do occasionally anyway on people we are concerned about).

  4. Seems like there should be a bit more feedback beyond “didn’t get sued, must have done that one OK”

  5. Thoracic aortic aneurysm?

    This is my guess not being a medical professional.

  6. Steve Radley md facep

    Could be an inhalant drug of abuse the marijuana look alike can do this “kp?” been seeing alot over late summer in dc metro area
    Can buy in the store. Although his age makes it unlikely.

  7. I can finish the story. The guy got better and was discharged. The cause of his pain was not determined but it was probably GERD. The CT finding was either an artifact or a non contributory anatomic variant.

    I don’t know about you but I see middle aged and older guys with highly dramatic chest pain and negative workups all day/all week/all month long.

  8. Heh, that brings back memories. I was injured in a car accident when I was 17 and taken to a good teaching hospital nearby (Truman Med Ctr, Kansas City, MO). Go figure, it was out-of-network. For 2 weeks I was too unstable to transfer (TBI plus assorted broken bones). Then no other hospitals would take me the next week because it was a major holiday. The insurance company did NOT like that!

    But I am thankful to all the doctors I encountered… I was in a pretty bad shape, and I’m awfully thankful to be alive…

  9. what prevented you from calling the doc in the receiving facilty…I do it all the time, was never was told ‘it is a HIPPA violation’….what ever happened to intellectual curiosity? you certainly learn a lot form those follow up calls

  10. This case was one that I was told about, so I don’t know the outcome.
    The other doc was frustrated because every time the diagnosis seemed certain, the diagnostic tests came up inconclusive.
    I also call about patients when I want follow up on a patient’s condition, but not all referring hospitals give out follow up information. I have gotten shut down due to “HIPAA compliance” more than once.

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