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 Screenshots

New!!!!!

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Time spent: 1dy

Status: Submitted

13hr 58min 29sec

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

1

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

developing

worksheet to

a differential

organize

diagnosis

your

list.

thoughts before

The following table summarizes your performance on each

sectionof the case, whether you completed that sectionor

not.

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1. Indicate key symptoms ( Sx ) you

the encounter

have

and

identified from the history. Start

symptoms

with the

patient's reason(s) for add additional obtained from

questioning.

symptom using "OLDCARTS". Capture the

and

further

2. Characterize

details

3. Review your

the

in

fin

din

gs

attributes

the

and

of

each

appropriate column

consider possible diagnoses

row.

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

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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

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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.

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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.

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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:

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Cardiac Examination

By

inspection:

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

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

Acute Coronary Syndrome (most probable)

Pericarditis excluded by absence of localized friction rub over pericardium.

Aortic Dissection excluded by absence of unequal pulsation or pulsating masses.

Musculoskeletal Pain excluded by not being aggravated by chest movement and not

being relieved by changing posture.

Pleurisy, Bronchitis, Broncho-Pneumonia or Lung Carcinoma excluded by absence of

cough, haemoptysis, friction rub on the chest and audible abnormal breathing

sounds.

Esophagitis or peptic ulcer excluded by absence of history of dysphagia, odynophagia,

hematemesis or heartburn.

Provisional Diagnosis

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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:

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

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

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

The patient should receive:

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

Oxygen inhalation session (5- 10 Litres / minute)

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

st

about intake of

sildenafil.

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:

Heparin SC injection (to prevent new thrombus formation)

Glycoprotein IIb & IIIa inhibitors.

Beta Blockers to decrease cardiac demands

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

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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,

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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

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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 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.

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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.