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Mr. Rosetti presented with left arm pain and chest pain that he has had for years. He came in today stating that his chest pain and arm pain has changed and over the past few days he has pain when he wakes up and intermittently throughout the day. He takes Procardia XL 60 mg every day for  blood pressure,  isosorbide dinitrate 40 mg three times a day for angina, and one or two nitroglycerine pills when he has chest pain.” HE does not smoke, drink or do any drugs. He denies injury and denies shortness of breath or dyspnea. I assessed Mr. Rosetti and his exam was rather benign. S1/S2 heart sounds could be heard. Breath sounds were clear. I ordered an EKG, a cbc, cmp, and a troponin right away. I wanted to ensure that he was not having an NSTEMI. All of his labs were within normal limits. Next, I ordered a chest x-ray and a CT chest to ensure there was no pneumonia or PE that could be causing pain. Both of those tests were negative. I ordered an Echo to assess his heart function and his EF was 40-45%. Finally, I ordered a stress test in which he was unable to complete due to pain and tachycardia along with EKG changes. Based on all of these findings I have come up with three differential diagnoses which include but are not limited to:

·     Unstable angina: Tabor & Whitmore (2018), explain that unstable angina occurs due to an acute obstruction of the coronary artery without myocardial infarction. These patients can present with chest pain/burning, left arm pain/numbness/tingling, angina that becomes more frequent even when resting, shortness of breath and more. In order to properly diagnose angina, it is important to obtain a troponin (if first one is negative may want to repeat in 8-12 hours), a CK-MB level, Chest x-ray, Echocardiogram and a CT chest to ensure the patient is not experiencing a life-threatening aortic dissection.  Patients with unstable angina should be admitted to the hospital, given aspirin and Plavix for antiplatelet management and nitroglycerin for the pain if not hypotensive or have not used a phosphodiesterase type 5 inhibitor within 24-48 hours. If the patient is experiencing unstable angina along with an NSTEMI then they need to have a cardiac catheterization performed within 24-48 hours of being admitted into the hospital for and necessary PCI.

·     Pericarditis: occurs when the pericardium of the heart becomes inflamed causing fluid buildup and irritation (Ismail, 2020). Patients that are suffering from pericarditis often complain that they have chest pain when they take a deep breath or lay down and it resolves if they sit up or lean forward. In order to diagnose pericarditis an EKG can be performed showing widespread saddle shaped ST elevation with PR depression. Laboratory tests that can be performed are a c-reactive protein as this will most often be elevated due to the inflammation. Patient’s must have two of the following in order to diagnose pericarditis: pericardial