Author: Anna Buehler, MD
Co Author #1: Charles A Tharp, MD
Co Author #2: Bradley G Changstrom, MD
Co Author #3: Julie Knoeckel, MD
Senior Editor: Natalie Stork, MD
Editor: Caitlyn Mooney, MD

Patient Presentation:
A 74-year-old woman presented with episodes of chest pain that began two days prior while paddle boarding.

History:
The pain was dull, encompassed the whole chest wall, and was associated with dyspnea. She initially believed the pain was caused by muscular strain and anxiety as she paddled in stormy conditions. The pain improved when she got to shore and resolved several hours after utilizing aspirin, acetaminophen, and a warm compress. The next day she had two more episodes with walking that resolved with the same initial interventions. The following day an episode was associated with minor exertion and did not improve. After presenting to the emergency department, the pain completely resolved with sublingual nitroglycerin. Her past medical history included hypertension (medications: amlodipine and losartan), rheumatoid arthritis (medications: etanercept), vasomotor symptoms (medications: oral estrogen), and elevated cholesterol.

Physical Exam:
The patient was a thin, healthy appearing older woman. She appeared anxious. Initial vital signs were a heart rate of 120 beats per minute with a regular rhythm and blood pressure of 164/102. Cardiac and pulmonary auscultation revealed no murmurs or abnormal heart sounds and lung fields that were clear without crackles. There was no jugular venous distension or lower extremity edema. The chest muscles appeared symmetric and there were no bony deformities or swelling around the sternum, clavicles or shoulders. Chest wall palpation did not reproduce the pain. Range of motion and strength of upper and lower extremities were normal.

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