Chest Pain

Medical History

[accordion][accordion_item title=”History of Present Illness”]Patient is a [AGE] year old [fe]male presenting with [left]-sided [chest pain] since [ONSET]. The symptoms started when the patient was [at rest] with [no] associated [shortness of breath,] [diaphoresis,] [nausea,] [lightheadedness]. The pain feels like [sharpness] and [non-radiating]. The onset of the pain were [sudden]. The pain was [not] reproducible to palpation. The patient reported [no] shortness of breath with activity at baseline. [Patient denies hemoptysis.] [Patient denies a history of clots or malignancy.] [Patient denies any leg swelling or pain.] The patient has a history of [hypertension].[/accordion_item][accordion_item title=”Physical Exam”]General: appear comfortable on stretcher.;
HEENT: mucous membranes moist;
Cardiovascular: [Normal rate], normal rhythm, no third or fourth heart sounds, no murmurs or rubs. Pulses are equal over the radial and carotid arteries bilaterally.;
Respiratory: Breath sounds are normal and non-stridorous. There are no crackles and  wheezes. There is no signs of accessory muscle use and abdominal breathing.;
Gastrointestinal: Soft, nontender, nondistended in all quadrants.;
Musculoskeletal: No associated ankle swelling;
Skin: No rash;
Neurologic: The patient is oriented to person, place and time. Strength and sensation are grossly intact. Face is symmetric.;[/accordion_item][/accordion]

Medical Decision Making

[accordion][accordion_item title=”Initial Evaluation and Differential”]Patient presents with chest pain.

I have considered life threatening causes of the patient’s symptoms, which includes acute coronary syndrome, pulmonary embolism, and aortic dissection.[/accordion_item][accordion_item title=”Diagnostics”]Non-Cardiac Chest Pain

  • Based on the history, PE, and considering the patient’s presenting signs and symptoms, I believe the patient has a clinical presentation that is not cardiac or pulmonary in etiology. Regardless, an ECG was ordered as a screening measure. The ECG was negative for any ST segment changes or T-wave inversions that may indicate an infarction.
  • I have considered and clinically ruled out an acute coronary syndrome as my history and physical exam does not support the diagnosis.
  • The patient’s has a calculated Well’s score of less than 2. Based on this, the patient has a very low probability of having a diagnosis of PE and does not warrant further testing.
  • I have considered and clinically ruled out a thoracic aortic dissection as my history and physical does not support the diagnosis.

Pain management

  • I have administered [4mg of IV morphine] [1 0.4mg sublingual nitroglycerin] to treat the patient’s probable cardiac pain.
  • I have administered 600mg of PO ibuprofen as the pain is likely musculoskeletal in origin.
  • I have administered a liquid antacid by mouth as the quality of the patient’s chest pain is likely gastrointestinal in origin.

ACS rule out

  • Based on the history, PE, and considering the patient’s presenting signs and symptoms, I believe the patient has a clinical presentation concerning for a cardiopulmonary etiology and justify further evaluation that includes an acute coronary syndrome rule out. Therefore, we have obtained an ECG and IV access was established by the nursing staff. Basic labs, cardiac enzymes, and coagulation studies were drawn.
  • Aspirin was administered.
  • The patient’s labs are significant for [a negative initial troponin]. [The patient has a negative repeat troponin at 3 hours post arrival.]

Chest X-ray

  • Due to my inability to exclude the diagnosis of an acute cardiopulmonary process, I decided to obtain an upright chest X-ray, which was not notable for no acute abnormalities.

No CT-Thorax

  • The patient has symmetrical pulses over the radial arteries and a normal X-ray. Based on this, the patient has a very low probability of having an aortic dissection and does not warrant further testing.

CT-Thorax

  • Due to my inability to exclude the diagnosis of an aortic dissection, I ordered a CT of the thorax with contrast, which demonstrated no sign of a dissection.

PE Testing

  • Based on the Well’s criteria and my clinical gestalt, the patient is risk stratified as [very low] [low][moderate][high] risk to have a clinically significant PE.
  • No testing
    • Therefore, no further testing is needed.
  • Negative testing
    • Therefore, a [d-dimer] was ordered and resulted to be negative, thereby ruling out the diagnosis of PE.
  • Positive d-dimer, negative testing
    • Therefore, a d-dimer was ordered and resulted to be positive. This was followed-up with a CT-PE protocol, which resulted to be negative, thereby ruling out the diagnosis of PE.
  • Positive d-dimer, positive testing
    • Therefore, a d-dimer was ordered and resulted to be positive. This was followed-up with a CT-PE protocol, which resulted to be positive for pulmonary embolism.
  • No d-dimer, positive testing
    • CT-PE was ordered and was positive for an embolism in [LOCATION].
    • After reviewing the absolute and relative contraindications to anticoagulation, IV [heparin] was initiated with with weight-based dosing by pharmacy.
    • Due to the critical nature of the patient’s clinical presentation, I consulted Cardio Team One regarding the possibility of emergent intravascular intervention. Per their recommendation, I have admitted the patient to the Cath Lab for emergent catherization.

NSTEMI

  • Based on the elevated troponins, I have made the diagnosis of a NSTEMI.
  • After reviewing the absolute and relative contraindications to anticoagulation, IV [heparin] was initiated with with weight-based dosing by pharmacy.
  • Per cardiology’s recommendation, I have administered [300mg of PO plavix] and admitted the patient to [CATH LAB/CCU] for further management.

STEMI

  • I have made the diagnosis of STEMI based on the patient’s abnormal ECG and activated Code STEMI. Per cardiology’s recommendation, I have admitted the patient to [cath lab] for further management.

[/accordion_item][accordion_item title=”Disposition”]Discharge

  • The patient has a TIMI score of <2. Based on the risk stratification for acute coronary syndrome, the patient’s risk profile is very low and thus does not necessitate admission. I have arranged the patient to have a follow-up with CTO Harper clinic in the next two days.
  • My clinical impression is that the patient has a presentation most consistent with a self-limiting and non-life threatening process. I have explained to the patient in appropriate terminology their diagnosis and provided anticipatory guidance for further management as an outpatient. I told them that we cannot definitively rule out a life-threatening cause of their symptoms during an emergency department visit, therefore they are absolutely required to follow-up with a physician to further assess them for risks of life-threatening causes of their presentation. If the patient cannot follow-up as an outpatient within a reasonable time period, that is, a few days, they should return to the ED so that we could help facilitate follow-up. I also explained to the patient that they were correct to present to the emergency department for this symptoms as I would prefer for them to err on the side of safety with this complaint and to continue to do so in the future. The patient has verbalized their understanding and at this time I feel they are stable for discharge home.
  • I have asked the patient to return to the ED should they experience worsening chest pain, vomiting, shortness of breath, coughing up blood, lightheadedness, or syncope.

Admit

  • The patient has a TIMI score of [#] based on [age greater than 65,] [more than 2 risk factors for coronary artery disease,] [known coronary artery stenosis,] [aspirin use in the last 7 days,] [more than 1 episode of severe angina in the last 24 hours,] [EKG ST changes greater or equal to 0.5mm,] [positive cardiac markers]. Based on the risk stratification for acute coronary syndrome, the patient’s risk necessitates admission to [the floor].

 

[/accordion_item][/accordion]