What is the appropriate workup for a 35-year-old patient who experiences a sensation of chest heaviness since undergoing knee surgery on November 15th, 2024, and reports possible inhalation of aluminum particles from his car's air conditioning (AC) system during valve replacement?

From the Guidelines

The workup for this 35-year-old patient with chest pressure sensation since knee surgery and concerns about aluminum particle inhalation should begin with a comprehensive history and physical examination, focusing on cardiopulmonary symptoms, as recommended by the American College of Cardiology Foundation/American Heart Association task force on practice guidelines 1. Initial testing should include:

• A chest X-ray to evaluate for pulmonary abnormalities
• Complete blood count to assess for infection or inflammation
• Basic metabolic panel
• An electrocardiogram to rule out cardiac causes, as suggested by the guidelines for assessing and managing asthma risk at work, school, and recreation 1 Pulmonary function tests would help evaluate respiratory mechanics and gas exchange. Given the temporal relationship with knee surgery, a D-dimer test and possibly CT pulmonary angiography should be considered to rule out pulmonary embolism, a serious post-surgical complication, as recommended by the evaluation of patients with suspected acute pulmonary embolism: best practice advice from the clinical guidelines committee of the American College of Physicians 1. For the concern about aluminum exposure, while acute toxicity from brief exposure is unlikely, an occupational/environmental history should be documented, as suggested by the guidelines for assessing and managing asthma risk at work, school, and recreation 1. If symptoms persist, referral to pulmonology would be appropriate for possible bronchoscopy or induced sputum analysis. Mental health screening is also important as the patient's symptoms could have a psychosomatic component, especially with the fixed belief about AC system particles despite the implausible timeline (November 2024 is in the future). The workup should address both physical and psychological aspects while maintaining a therapeutic alliance with the patient. It is essential to follow the guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction, which recommend a rapid clinical determination of the likelihood risk of obstructive CAD and early risk stratification for the risk of cardiovascular events 1. Additionally, the guidelines suggest that a 12-lead ECG should be performed and shown to an experienced emergency physician as soon as possible after ED arrival, with a goal of within 10 min of ED arrival for all patients with chest discomfort or other symptoms suggestive of ACS 1. Cardiac biomarkers, including cardiac-specific troponin, should be measured in all patients who present with chest discomfort consistent with ACS, as recommended by the guidelines 1.

From the Research

Initial Assessment

The patient is a 35-year-old who underwent knee surgery on November 15th, 2024, and now complains of feeling like there is someone on his chest. He also mentions that he has been breathing in aluminum particles, possibly from his car's AC system.

Potential Causes

• Cardiac issues: The feeling of someone on his chest could be related to cardiac problems, such as acute coronary syndrome (ACS) 2, 3.
• Respiratory issues: Breathing in aluminum particles could cause respiratory problems, but there is no direct evidence in the provided studies to support this claim.
• Anxiety or stress: The patient's symptoms could also be related to anxiety or stress, especially after a recent surgery.

Diagnostic Workup

• Cardiac enzymes: Checking cardiac enzymes such as troponin T could help diagnose ACS 2, 3.
• Electrocardiogram (ECG): An ECG could help identify any cardiac abnormalities 4.
• Complete Blood Count (CBC): A CBC could be useful in assessing cardiovascular and metabolic diseases, although its utility in this specific case is unclear 5.
• Imaging tests: Depending on the results of the initial workup, imaging tests such as a chest X-ray or cardiac magnetic resonance (CMR) may be necessary 2, 6.

Next Steps

• The patient should undergo a detailed history, physical examination, and ECG to rule out any cardiac abnormalities 4.
• Cardiac enzymes such as troponin T should be checked to diagnose ACS 2, 3.
• A CBC could be considered to assess cardiovascular and metabolic diseases, although its utility in this specific case is unclear 5.
• Further testing, such as imaging tests, may be necessary depending on the results of the initial workup.