I HUMAN CASE WEEK #7 49 YEAR OLD PATIENT, REASON FOR ENCOUNTER -INTERMITTENT SQUEEZING CHEST PAIN (C

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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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The following sectionof the not.

table summarizes case, whether

Time spent: 1dy Status: Submitted

13hr

Case

Section

Status

History

Done

your you

performance on completed that

58min 29sec

Your Score

Time spent

63%

12hr 5mi

Performance

Done

83%

13hr 52min 55sec

Done

Key findings organization

Details

60

questions asked, 22 to the case'slist

correct, 13

53

exams performed, partially correct, 0 case's list

19 correct, 1 missed relative to

the

14

findings listed;

16

listed

by

the

case

150

words

long;

the

case's

was

117

words

13

items missed

in the relative to

DDx, 7 the case'slist

correct, 1

10

tests ordered, 8 relative to the

correct, 1 case's list

missed

1645

words

long;

case's

was

79

words

3

of 1

5 correct partially correct

(of

scored

items

only)

n 12sec Physical exams

each sectionor

relative

34min 40sec Done

Problem statement

1hr 9mi n 29sec

Differentials

Done

88% 13min 14sec

Differentials ranking

Done

88% (lead/alt score) 88% (must not miss score)

Tests

Done

89%

7min 38sec

50min 23sec Diagnosis

Done

100%

21sec

Done

Management plan

the

46min 0sec

Exercises

Done 68% (of scored items only)

32min 51sec

AA

History Notecard Use this developing

missed

by

AA

worksheet to a differential

on

case

organize diagnosis

your list.

thoughts

before

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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

=

Onset

2.5 hours

Location

deepin through

Sx Sx Sx Sx Sx = = = = =

chest pain ago

chest, back

pierces

Duration Characteristics

worsens with deep inspiration

Aggravating

worsens when laying down, moving, and breathing eased pain when leaning forward

Relieving Timing / Treatments Severity

History of

8/10

Present Illness

Category Reason

for

Encounter

Data

entered

Chest

pain

by

AA

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History

of

present illness

Past

Medical

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.

Data

entered

History by

AA

inferolateral PCI/stenting Balloon angioplasty

wall of of

ST-elevation the right the left

Category

Data

by

AA

Medications

Clopidogrel Atorvastatin Pantoprazole Aspirin 81

mg mg mg QD

QD QD QD

by

AA

by

AA

Category Past

Medical History

Hospitalizations

/

Hypertension Hyperlipidemia

Surgeries

Acute

myocardial coronary artery circumflex

Medications entered 75 80 40 mg

at

bedtime

Allergies Category

Data

Allergies

Bactrim (rash)

Preventive

Health

Category Preventive

entered

health

Data

entered

Up

to date immunization annually. Reports gynecology normal.

Data

entered

including flu exam was

Family History Category Family

History

Social History

Father Mother Sister -

Heart Type Type

by

AA

attack, 2 2

59 years Diabetes Diabetes

old

shots

infarction with (RCA). artery.

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Data

Category Social

History

entered

by

AA

Freelance worker, telephone half for the the heart attack

sales. past and

Category

Data

entered

by

AA

General

Slightly

fatigued. Laying

still

to

Warm

skin;

significant

Denies

any problems with headaches, double night vision, hearing problems, ear problems, chronic sore throats, or

Review of

pack and Quitted since healthy heart

a she’d diet.

Systems

Integumentary

/

HEENT

Neck

/

Smoked a 25 years. takes a

Breast

Cardiovascular

Chest pain.

Denies history Hypertension Hyperlipidemia

no

Heart of

movement,

breathing slowly.

diaphoresis.

attack 10 days irregular heartbeats

ago. nor

vision, difficulty with pain, sinus difficulty swallowing.

palpitations.

Respiratory

Denies

Gastrointestinal

Reports mild

nausea

Genitourinary

Denies

urinary

frequency,

pain,

Musculoskeletal

Denies

chest

injury.

problems with

muscles and

joints.

Denies

problems with heat or cold increased sweating, frequent urination, or

intolerance, change in

increased thirst, appetite.

No

reports sites

nose

or

Neurologic

Denies

dizziness, seizures, numbness,

Psychiatric

Reports nervousness

due

to

Data

entered

by

AA

Obese AOx4 Skin

with

a

BMI

of

is

dry

and

febrile.

Allergic /

Physical Category General

Skin

sputum production. and

No

reflux. incontinence,

or

difficulty.

Immunologic

Endocrine

Hematologic

wheezing and

avoid

/

Lymphatic

of of

bruising, bleeding gums, increased bleeding.

or

weakness.

chest

pain.

Exams

Skin warm Nails without Capillary refill Quincke’s Test:

and dry with ridging, pitting, or < 2 sec.

Blanching observed.

bleeds,

29.4.

no lesions. peeling.

other

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HEENT

/

Neck

Head:

Cardiovascular

Chest

/

Respiratory

Abdomen

Genitourinary

/

Rectal

Normocephalic, atraumatic, symmetric.Temporal arteries Frontal and maxillary sinuses Eyes: Normal conjunctivae on Snellen pocket card: OD Throat/Neck: Mucous membranes erythema, edema, or body.

No visible scars, on neck inspection. mobile. JVP WNL

no deformities, non-tender to non-tender. inspection.

Visual 20/20, OS 20/20. moist. Oropharynx exudate. No stridor, deformities, or Trachea is midline

facial features palpation.

PMI

No significant Valsalva maneuver

change or

nondisplaced.

JVP standing, squatting, sustained handgrip.

WNL. during

Thorax

atraumatic; no postsurgical scars. normal rate, nonlabored.

No visible chest.

No tenderness to chest body palpation.

No palpable thrill.

Thorax normal/symmetrical to percussion.

Normal lungs sounds bilaterally.

acuity

with

without no foreign other lesions and freely

while with

Respirations bounding of wall or Normal tactile

shallow, the vertebral fremitus.

Abdomen atraumatic, obese, nondistended.

No hepatosplenomegaly or nontender throughout exam.

Normoactive bowel palpable masses. Soft,

sounds.

Normal pelvic exam. genitalia.

tenderness.

No

masses

or

Normal external

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

Psychiatric

AOx4

Lymphatic

No

II-XII

pathologically supraclavicular,

intact.

enlarged lymph axillary or

nodes in inguinal chains.

the

cervical,

*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 & peripheraltoperipheral 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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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.

2.

3.

4.

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.

5.

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.

6.

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: 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 1st 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.

10.

Primary PCI within 90 minutes (if available) 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 Presentation Diagnosis

Presentation

Pulmonary embolism

Sudden onset, pleuritic pain, and dyspnea

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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 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 STsegment 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 setting of 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 without any 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 the presence 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 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.