I-Human Case Study: Intermittent Squeezing Chest Pain in a 49-Year-Old Patient, Exams of Nursing

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Comprehensive I-Human Case Week #7, 49-Year -

Old Patient Reason for Encounter: Intermittent

Squeezing Chest Pain Latest Study Case Actual

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1. Indicate key symptoms ( Sx ) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning.
2. Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row.
3. Review your findings and consider possible diagnoses that may correlate with these symptoms.(Remember to consider the patient's age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case. HPI Sx = chestpain Sx Sx Sx Sx Sx = = = = = Onset 2.5 hours ago Location deepin chest, pierces through back Duration Characteristics worsens with deep inspiration Aggravating worsens when laying down, moving, and breathing Relieving eased pain when leaning forward Timing / Treatments Severity 8/

History of Present Illness

Category Data entered by AA

Reason for Encounter Chest pain

History of present illness A 57-year-old female 10 days status post inferolateral STEMI with stent placement, presents to the ED with a 2.5-hour history of progressively worsening chest pain. The pain is sharp and stabbing, gets to pierce through her back with inspiration. Pain is partially relieved by sitting up and leaning forward. She reports mild nausea without vomiting, denies fever/chills, palpitations, lightheadedness/syncope, SOB, cough, URI, or extremity/catheterization site pain or swelling. She reports compliance with her antiplatelet medications (ASA and clopidogrel), pantoprazole, and aspirin since discharge. On exam, patient is febrile, shallow respirations at normal rate, low-normal oxygen saturation, and has pericardial friction rub. PMH is significant for hypertension, hyperlipidemia, tobacco abuse, obesity, and family history of heart attack and type-2 diabetes.

Past Medical History

Category Data entered by AA

Past Medical History Hypertension Hyperlipidemia Hospitalizations / Surgeries Acute inferolateral wall ST-elevation myocardial infarctionwith PCI/stenting of the right coronary artery (RCA). Balloon angioplasty of the left circumflex artery.

Medications

Category Data entered by AA

Medications Clopidogrel 75 mg QD Atorvastatin 80 mg QD at bedtime Pantoprazole 40 mg QD Aspirin 81 mg QD

Allergies

Category Data entered by AA

Allergies Bactrim (rash)

Preventive Health

Category Data entered by AA

Preventive health Up to date immunization including flu shots annually. Reports gynecology exam was normal.

Family History

Category Data entered by AA

Family History Father - Heart attack, 59 years old Mother - Type 2 Diabetes Sister - Type 2 Diabetes

Social History

HEENT / Neck Head: Normocephalic, atraumatic, no deformities, facial features symmetric.Temporal arteries non-tender to palpation. Frontal and maxillary sinuses non-tender. Eyes: Normal conjunctivae on inspection. Visual acuity with Snellen pocket card: OD 20/20, OS 20/20. Throat/Neck: Mucous membranes moist. Oropharynx without erythema, edema, or exudate. No stridor, no foreign body. No visible scars, deformities, or other lesions on neck inspection. Trachea is midline and freely mobile. JVP WNL Cardiovascular PMI nondisplaced. JVP WNL. No significant change while standing, squatting, during Valsalva maneuver or with sustainedhandgrip. Chest / Respiratory Thorax atraumatic; no postsurgical scars. Respirations shallow, normal rate, nonlabored. No visible bounding of the chest. No tenderness to chest wall or vertebral body palpation. No palpable thrill. Normal tactile fremitus. Thorax normal/symmetrical to percussion. Normal lungs sounds bilaterally. Abdomen Abdomenatraumatic, obese, nondistended. Normoactive bowel sounds. No hepatosplenomegaly or palpable masses. Soft, nontender throughout exam. Genitourinary / Rectal Normal pelvic exam. No masses or tenderness. Normal external genitalia. Musculoskeletal / Normal muscle bulk. No evidence of swelling. Osteopathic Structural No calf tenderness or inflammatory signs. No Examination peripheral edema. No asymmetry or deformity of the back. No tenderness or spasm of the paraspinal muscles. No localized tenderness of the spinous processesor pelvic structures. Neurologic PERRLA.CN II-XII intact. Psychiatric AOx Lymphatic No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary or inguinal chains. *History of present illness Patient known to be ischemic heart. Recently he developed retrosternal burning and compressing chest pain, with acute onset intermittent course for 5 hours. Not radiating , not relieved by sublingual nitrates , not associated with dyspnea. there is no history of syncope, palpitation, bluish discoloration of peripheries or lower limb oedema.

The pain is not aggravated by chest movement and not relieved by changing posture. There is no cough, haemoptysis, or audible breathing sounds. There is no history of dysphagia, odynophagia, hematemesis or heartburn. There is no history of chest trauma. There were no symptoms suggesting other systems affection. *Past History Patient has history of PCI since 2 years. The patient condition started 3 years ago when he had similar attacks of chest pain that occurred repeatedly despite receiving sublingual Nitro glycerine tablets. There are no other chronic diseases, no drug allergy, no history of operations and no blood transfusion *Family History There are no chronic disease running in family or similar attacks. Emergency Department Examination 1ry Survey: Airway: The patient has patent airways Breathing: By Inspection, the Respiratory Rate is 14 breathes / minute, there is symmetrical chest movements and there is no chest deformity. By Palpation, There is no chest tenderness, there is symmetrical chest expansion & there is no shifting of trachea. By Percussion, No Hyper-resonance By Auscultation, No Abnormal Breathing sounds. Circulation: Central Pulsation is felt, central to peripheral pulsation is comparable & peripheral-toperipheral pulsation is also comparable. Radial pulsation is 63 beats per min, regular, of average volume, symmetrical in both sides and has no special characters. Blood Pressure: 115 / 85 mmHg (Normal) Capillary Filling time: less than 2 seconds. Disability:

A 58 years old male ischemic patient came complaining of intermittent retrosternal sever

chest tightness, with no radiation for 5 hours duration most probably caused by UnStable

Angina Pectoris not complicated.

Management

The patient should be admitted and have the following investigations:

1. 12 Leads ECG for any abnormal findings including T-wave inversion or ST segment elevation.

2. Cardiac enzymes (Myoglobin, Troponin I and CK MB.)

3. Chest X ray (for exclusion of trauma, pulmonary conditions & aortic aneurysm).

The patient should receive:

1. Aspirin 300 mg for chewing (to prevent propagation of the thrombus)

2. Oxygen inhalation session (5-10 Litres / minute)

3. Nitro glycerine 10 mg sublingual tablets (for coronary vasodilatation) >> ask 1

st

about intake

of sildenafil.

4. Morphine 5-10 mg IV (for relieving pain)

If the patient’s condition improved he should be put under observation for 24 hours.

Drugs taken after stabilization of the condition:

5. Heparin SC injection (to prevent new thrombus formation)

6. Glycoprotein IIb & IIIa inhibitors.

7. Beta Blockers to decrease cardiac demands

8. Diltiazim (if beta blockers are contraindicated, e.g. Asthma)

If the patient’s condition didn’t improve or MI was present

9. Primary PCI within 90 minutes (if available)

10. Thrombolytics if PCI is not available (unless absolutely Contraindicated)

Scientific background

Chest pain

INTRODUCTION

Patients with acute no traumatic chest pain are among the most challenging patients cared for by emergency

physicians. They may appear seriously ill or completely well and yet remain at significant risk for sudden death or an

acute myocardial infarction (AMI).

CLINICAL FEATURES

The typical pain of myocardial ischemia has been described as retrosternal or epigastric squeezing, tightening, crushing,

or pressure-like discomfort. The pain may radiate to the left shoulder, jaw, arm, or hand. In many cases, particularly in the

elderly, the predominant complaint is not of pain, but of a poorly described visceral sensation with

associated dyspnea, diaphoresis, nausea, lightheadedness, or profound weakness. The onset of symptoms may

be sudden or gradual, and

Symptoms usually last minutes to hours. In general, symptoms that last less than 2 minutes or are constant over days

are less likely to be ischemic in origin. Symptoms that are new or familiar to the patient but now occur with

increasing frequency, severity, or at rest are called unstable and warrant urgent evaluation even if they are absent at

the time of presentation. Cardiac risk factors should be used only to predict coronary artery disease within a given

population and not in an individual patient. It should also be mentioned that women, diabetics, and patients with

psychiatric disorders may have more subtle signs of ischemia.

PHYSICAL EXAMINATION

Patients with acute myocardial ischemia may appear clinically well or be profoundly hemodynamically unstable.

The degree of hemodynamic instability is dependent on the amount of myocardium at risk, associated

dysrhythmias, or preexisting valvular or myocardial dysfunction.

Worrisome signs may be clinically subtle, particularly the presence of sinus tachycardia, which may be due to pain

and fear or may be an early sign of physiologic compensation for left ventricular failure. Patients with acute ischemia

often have a paucity of significant physical findings. Rales, a third or fourth heart sound, cardiac murmurs, or rub are

clinically relevant and important findings.

The presence of chest wall tenderness has been demonstrated in 5 to 10 percent of patients with AMI, so its

presence should not be used to exclude the possibility of acute myocardial ischemia.

Also, response to a particular treatment such as nitroglycerin should not be taken as evidence of a certain disease.

DIAGNOSIS AND DIFFERENTIAL Electrocardiography

Of all the diagnostic tools clinically used in assessing chest pain, the electrocardiogram (ECG) is the most

reliable when used and interpreted correctly. Patients with acute infarctions may have ECG findings that

range from acute ST-segment elevations to completely normal. This range means that the ECG is useful only

when it has a positive, or diagnostic, finding. New ST-segment elevations, Q waves, bundle branch block,

Aortic dissection

Pericarditis

Pneumothorax

Acute coronary syndrome

Esophageal rupture

Tearing pain with radiation to back, neurologic symptoms

Positional ache, dyspnea

Pleuritic pain and dyspnea

Vague, pressure-like pain, radiation to arm, neck, jaw

Constant retrosternal, epigastric pain, history of inciting event

Pneumonia Pleuritic pain, cough, dyspnea, chills

SPECIFIC CAUSES OF CHEST PAIN Angina Pectoris

The pain of chronic stable angina is episodic and lasts 5 to 15 minutes. It is precipitated by

exertion and relieved with rest or sublingual nitroglycerin within 3 minutes. The pain is

typically visceral in nature (aching, pressure, and squeezing), with radiation to the neck, jaw,

arm, or hand. In individual patients the character of each attack varies little with recurrent

episodes. Most patients can differentiate their usual angina from other causes of pain.

Physicians evaluating patients with stable angina should screen carefully for changes in the

pattern that would suggest a shift from stable to unstable angina or even suggest a different

diagnosis.

Unstable Angina :

Patients who complain of recent onset of angina, changes in the character of the angina, or

angina at rest are thought to have an unstable pattern of their angina. They are at risk for

an AMI or sudden cardiac death (see Chapter 21 for management).

Variant (Prinzmetal) Angina

This form of angina is thought to be due to spasm of the epicardial vessels in patients with

normal coronary arteries (one third of cases) or in patients with underlying atherosclerotic

disease (two thirds of cases). Pain typically occurs at rest and may be precipitated by the

use of tobacco or cocaine. The ECG typically shows ST- segment elevations during an

acute attack.

Acute Myocardial Infarction

Ischemic pain that lasts longer than 15 minutes, is not relieved by nitroglycerin, or is

accompanied by diaphoresis, dyspnea, nausea, or vomiting suggests the diagnosis of AMI.

The clinician must understand the limitations of the screening tools used in the ED and

should have a high level of suspicion for AMI in patients with risk factors and prolonged or

persistent symptoms for whom there is no other clear diagnosis. Aortic Dissection

This diagnosis should be suspected in the patient who complains of sudden onset of severe,

tearing pain in the retrosternal or midscapular area. High-risk patients are also those at risk for

AMI, specifically the middle-age hypertensive male. The patient may be hypertensive or

Gastrointestinal Causes

Esophageal reflux, dyspepsia syndromes, and esophageal motility disorders can produce chest

pain that is difficult to distinguish from ischemic pain. Patients may complain of burning,

gnawing pain associated with an acid taste radiating into the throat. Pain may be exacerbated

by meals, worsen when supine, and may be associated with belching. Clinicians should

determine whether the symptoms are due to a GI disorder based on the clinical presentation and

the absence of findings and/or risk factors suggesting an ischemic cause. Diagnostic decisions

should not be made on the basis of a response to a therapeutic trial of antacids, GI cocktails, or

nitroglycerin.

EMERGENCY DEPARTMENT CARE AND DISPOSITION

Assume that every patient complaining of chest pain might be having an AMI.

Patients with suspicious histories should have large-bore IV line established, a cardiac

monitor, supplemental O2, and ECG obtained as soon as possible. Vital signs and pulse

oximetry should be monitored continuously.

Ask patients about cardiac risk factors, preexisting coronary artery disease, quality of chest

pain, time of onset and duration of symptoms, and whether the pattern has been stable,

unstable, continuous, or intermittent. Ask specifically for clues to noncardiac causes of chest

pain: ability to elicit pain by movement or cough; the relation of pain to meals; or pain that is of

sudden onset, referred to the back, or pleuritic in nature.

Examine patients while noting evidence of heart failure or valvular insufficiency,

pericardial rubs, or tenderness of the chest wall. Specifically, physicians should ask whether

pain elicited on palpation of the chest wall exactly reproduces the patient's pain.

An ECG should be obtained on all patients for whom there is a reasonable suspicion of

myocardial ischemia. A normal ECG, although minimizing the likelihood of an AMI, does not

definitively rule out the possibility of MI.

If the etiology of chest pain remains unclear in some patients, clinicians should consider

more diagnostic tests as guided by clinical suspicion and findings.

Clinicians should not use patients' clinical response to GI cocktails, nitroglycerin, or

NSAIDs to exclude the possibility of myocardial ischemia.

In patients with nondiagnostic ECGs for whom there is a clinical suspicion for ischemia, clinicians

should consider provocative testing, echocardiography, or admission and observation.

Physicians should not rely on serum enzyme testing to rule out the possibility of

clinically significant disease.