GIM Question 2 Instructor

You are called to the ward because of a patient with sudden onset chest pain.

  1. Outline your initial steps.

    An initial approach for this patient involves obtaining the following:

    • History – onset, location, provoking/relieving factors, quality, radiation, severity, past history of similar pain, associated symptoms (diaphoresis, nausea, breathlessness, vomiting, hemoptysis, relationship of pain to food (r/o GERD or other esophageal etiologies), melena/hematochezia.Be sure to ask closed-ended, targeted questions, as a patient with acute chest pain will not tolerate a lot of talking.
    • Past Medical History – similar symptoms, ACS, GERD
    • Acquire data from patient chart – reason for admission, medications, past medical history
    • Physical exam – vitals (HR, BP, RR, O2 sat, Temp), cardiac exam, respiratory exam
  2. What investigations would you order?
    Investigations to order at this time:

    • CBC, lytes
    • ECG, Troponin, CK
    • Chest xray
    • CT Pulmonary Embolism if suspect PE
  3. Assuming your tests suggest an acute coronary syndrome (but no STEMI), what is your initial management at this time?
    Put the patient on a monitor or telemetry
    O2 supplementation (if O2 sat<94% or respiratory distress)In the event of ACS:

    • Aspirin 81mg 2tab PO chew
    • Metoprolol 25mg PO (if BP is elevated)
    • Nitroglycerine 0.4mg spray SL (if BP will support)
      Consult cardiology.

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