Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Chest Pain in a Patient With Coronary Artery Disease – I


Case Study

A rapid response event was initiated by the bedside nurse for acute onset hypotension. On prompt arrival of the rapid response team, it was noted that the patient was a 66-year-old female with a known history of ST-elevation myocardial infarction (STEMI) status post coronary artery bypass grafting a year ago, hypertension, and type 2 diabetes. She initially presented to the hospital for right flank pain and was being treated for a urinary tract infection. Upon further questioning at the bedside, the patient mentioned that she had been having substernal chest pain for the past 1 h. Her chest pain had continued to worsen, and she now had associated diaphoresis and tachypnea.

Vitals Signs

  • Temperature: 37.4 °F, axillary

  • Blood Pressure: 90/40 mmHg

  • Pulse: 105 beats per min (bpm), sinus tachycardia on telemetry (see Fig. 1.1 )

    Fig. 1.1, Telemetry strip showing lead ii with a heart rate of 105 bpm, and sinus rhythm

  • Respiratory Rate: 22 breaths per min

  • Pulse Oximetry: 99% on room air

Focused Physical Examination

The patient was an elderly female who was in moderate distress, holding her chest and appeared diaphoretic. She responded briefly to her name but swiftly stopped responding to further commands. She was moving all her limbs spontaneously. The heart rate was 105-110 bpm, with a regular rhythm and no murmurs. The abdominal exam did not elicit any tenderness, and the rest of her physical exam was benign.

Interventions

The patient was given a 1 L fluid bolus which increased her blood pressure to 120/70 mmHg. A complete metabolic panel, troponin level, and magnesium levels were ordered. An EKG was done, which showed sinus tachycardia, with no acute ischemic findings. Chest X-ray at bedside showed no evidence of pneumothorax, consolidation, widened mediastinum, or enlarged aortic knob and no evidence of fluid overload. The pretest probability of PE was low, so a d-dimer test was ordered, which was normal. The patient was given one dose of 0.3 mg sublingual nitroglycerin (NTG), which improved her chest pain. Based on her cardiac history and current presentation, she was loaded with 325 mg of aspirin and 600 mg of clopidogrel and started on a therapeutic dose of enoxaparin after consultation with cardiology.

Final Diagnosis: Unstable AnginA

Generalized Approach to Acute Severe Chest Pain

There is a wide range of causes of chest pain in a rapid response setting, but the differential can be narrowed down with an organized history, physical, and appropriate workup. Chest pain is the second most common presenting complaint in the United States, with 7.6 million emergency department visits yearly. Prompt recognition and exclusion of the life-threatening differentials of chest pain are of paramount importance. However, it can be tricky at times as patients may appear deceptively well ( Table 1.1 ). This emphasizes the importance of appropriate workup.

Table 1.1
Differential diagnosis of chest pain
Life-threatening Non-life-threatening
Acute coronary syndrome Lung infection
Acute aortic dissection Pericarditis
Pulmonary embolism Gastroesophageal reflux disease
Tension pneumothorax Costochondritis
Pericardial tamponade Panic attack
Esophageal rupture Aortic stenosis

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts