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.