I-Human Case Study: Chest Pain in a 57-Year-Old Female Post-STEMI, 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 Screenshots

New!!!!!

Time spent: 1dy 13hr 58min 29sec

Status: Submitted

Case Section Status Your Score Time spent Performance Details History Done 63% 12hr n 12sec 5mi 60 questionsasked, 22 to the case'slist correct, 13 missed relative Physical exams Done 83% (^) 13hr 52min 55sec 53 exams performed, partially correct, 0 case's list 19 correct, missed relative

to the Key findings organization Done 34min 40sec 14 findings listed; 16 listed by the case Problem statement Done 1hr n 29sec 9mi 150 words long; the case's was 117 words Differentials Done 88% 13min 14sec 13 items in the missed relative to DDx, 7 the case'slist correct, 1 Differentials ranking Done 88% (lead/alt score) 88% (must not miss score) 7min 38sec Tests Done 89% 50min 23sec 10 tests ordered, 8 relative to the correct, 1 case's list missed Diagnosis Done 100% 21sec Management plan Done 46min 0sec 1645 words long; the case's was 79 words Exercises Done 68% (of scored items only) 32min 51sec 3 of 5 correct 1 partially correct (of scored items only)

AA

HistoryNotecard by AA on case

Use this worksheet to organize your thoughts before

developing a differential diagnosis list.

The following table summarizes your performance on each sectionof the case, whether you completed that sectionor not.

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 the case. guide your physical examination in the next section of 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

Category Data entered by AA

Social History Freelanceworker, telephone sales. Smoked a pack and a half for the past 25 years. Quitted since she’d the heart attack and takes a healthy heart diet.

Review of Systems

Category Data entered by AA

General Slightly fatigued. Laying still to avoid movement, breathingslowly. Integumentary / Breast Warm skin; no significant diaphoresis. HEENT / Neck Denies any problems with headaches, double vision, difficulty with night vision, hearing problems, ear pain, sinus problems, chronic sore throats, or difficulty swallowing. Cardiovascular Chest pain. Heart attack 10 days ago. Denies history of irregular heartbeats nor palpitations. Hypertension Hyperlipidemia Respiratory Denies wheezing and sputum production. Gastrointestinal Reports mild nausea and reflux. Genitourinary Denies urinary frequency, pain, incontinence, or difficulty. Musculoskeletal Denies chest injury. No problems with muscles and joints. Allergic / Immunologic Endocrine Denies problems with heat or cold intolerance, increasedthirst, increasedsweating, frequent urination,or change in appetite. Hematologic / Lymphatic No reports of bruising, bleeding gums, nose bleeds, or other sites of increasedbleeding. Neurologic Denies dizziness, seizures, numbness, or weakness. Psychiatric Reports nervousness due to chest pain.

Physical Exams

Category

Data entered by AA

General Obese with a BMI of 29.4. AOx Skin is dry and febrile. Skin Skin warm and dry with no lesions. Nails without ridging, pitting, or peeling. Capillary refill < 2 sec. Quincke’sTest: Blanchingobserved.

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 / Osteopathic Structural Examination Normal muscle bulk. No evidence of swelling. No calf tenderness or inflammatory signs. No 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:

The Patient is Alert on AVPU Score. The pupils are rounded, central, responsive to light & equal on both sides. Exposure: No apparent injuries in body. General Examination Patient is alert , conscious , oriented to time , place and persons , average built , quiet facial expression , no special decubitus , average intelligence ,he's cooperative Cardiac Examination By inspection: There is no skin redness, pigmentation, ulceration, fistulae or scars. Respiration is abdomenothoracic. No visible pulsation at the apex of the heart. By Palpation: Palpable pulsation of the heart at the fifth intercostal space in the midclavicular line. There are no masses, swellings, tenderness or pulsating masses. By Auscultation: No abnormal cardiac sounds, muffling or murmurs were heard at the apex of the heart, xiphisternal area and aortic areas. Differential Diagnosis

1. Acute Coronary Syndrome (most probable)
2. Pericarditis excluded by absence of localized friction rub over pericardium.
3. Aortic Dissection excluded by absence of unequal pulsation or pulsating masses.
4. Musculoskeletal Pain excluded by not being aggravated by chest movement and not being relieved by changing posture.
5. Pleurisy, Bronchitis, Broncho-Pneumonia or Lung Carcinoma excluded by absence of cough, haemoptysis, friction rub on the chest and audible abnormal breathing sounds.
6. Esophagitis or peptic ulcer excluded by absence of history of dysphagia, odynophagia, hematemesis or heartburn. Provisional Diagnosis

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

INTRODUCTION

Chest pain

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,

and T-wave inversions or normalizations are strongly suggestive of ischemia and warrant aggressive management in the emergency department (ED). The presence of a normal or unchanged ECG does not rule out the diagnosis of acute myocardial ischemia. Serum Markers Serum markers, if positive, are highly specific for AMI. Myoglobin rises predictably in AMI but is found in all muscle tissue, making it less reliable in the setting of AMI. Creatinine kinase and its MB isoenzyme constitute the historical gold standard for diagnosing AMI. Cardiac-specific troponin I is not found in skeletal muscle, so it has a much greater sensitivity and specificity for AMI. The documentation of normal serum markers in the bloodstream does not exclude the diagnosis of AMI. In addition, these enzymes will not become elevated in serious disease conditions such as unstable angina. The use of these markers can aid the clinician in assessing risk for patients with chest pain, including disposition within the hospital. It must be remembered that a serial enzyme evaluation is needed to appropriately risk stratify individual patients. Echocardiography Emergency 2-dimensional echocardiography may have value in the evaluation of chest pain when the ECG is nondiagnostic, eg, in patients with pacemakers, have a bundle branch block, or have a baseline abnormal ECG. The finding of regional wall motion abnormalities in the acutely symptomatic patient is strongly suggestive of active ischemia. Wall motion abnormality also may represent previous myocardial injury. Twodimensional echocardiography also may aid in the diagnosis of other conditions that may mimic ischemic disease, such as pericarditis, aortic dissection, or hypertrophic cardiomyopathy. Provocative Tests Many tests currently being performed in some EDs will unmask otherwise unrecognized, clinically significant ischemic disease. Patients with atypical chest pain and a normal stress thallium or technetium scan have a very low incidence of short- and long-term subsequent ischemic events. Thallium or sestamibi testing can be done in the ED to further risk stratify patients in the hospital and perhaps be used in consideration for patient discharge from the ED. Differential Diagnosis The priority must always be to exclude life-threatening conditions, and the ED physicians should organize their test-ordering strategies to screen for those conditions first. (Table lists possible causes of nontraumatic chest pain.)

Table Serious Causes of Chest Pain and Their

Presen

tation

Diagnosis Presentation

Pulmonary embolism Sudden onset, pleuritic pain, and dyspnea

Aortic dissection Tearing pain with radiation to back, neurologic symptoms

Pericarditis Positional ache, dyspnea

Pneumothorax Pleuritic pain and dyspnea

Acute coronary syndrome Vague, pressure-like pain, radiation to arm, neck, jaw

Esophageal rupture 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 andrelieved 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 screencarefully 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 atrest 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

hypotensive in shock. There may be a diastolic murmur of aortic regurgitation, indicating a proximal dissection, or distal pulse deficits, indicating a distal dissection. The dissection may occlude coronary ostia, resulting in myocardial infarction, or the carotids, resulting in cerebral ischemia and stroke. Chest x-ray, computed tomography, trans esophageal echocardiography (TEE), and angiography can aid in the diagnosis of this condition. Musculoskeletal Causes Chest pain due to irritation or inflammation of structures in the chest wall is commonly seen in the ED. Possible causes include costochondritis, intercostal strain due to severe coughing, and pectoralis muscle strain in the settingof recent physical exertion. Patients will complain of sharp pain that is worsened with movement of the chest wall (eg, coughing, and some pain that can be elicited by palpation of the chest wall). These findings in patients withoutany other symptoms and no history of significant cardiac disease support the diagnosis of musculoskeletal pain. This pain is generally responsive to no steroidal anti-inflammatory drugs. It is important to emphasize that thepresence of chest wall tenderness does not rule out the possibility of myocardial ischemia.

Gastrointestinal Causes Esophageal reflux, dyspepsia syndromes, and esophageal motility disorders can produce chest pain that is difficultto 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 bemonitored 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 ofthe 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 thepossibility of MI. If the etiology of chest pain remains unclear in some patients, clinicians should consider more diagnostictests as guided by clinical suspicion and findings. Clinicians should not use patients' clinical response to GI cocktails, nitroglycerin, or NSAIDs to excludethe possibility of myocardial ischemia. In patients with nondiagnostic ECGs for whom there is a clinical suspicion for ischemia, clinicians shouldconsider provocative testing, echocardiography, or admission and observation.

Physicians should not rely on serum enzyme testing to rule out the possibility of clinically significant disease.