Has he ever had pain like this before?
Does the pain go anywhere apart from in his chest?
What type of pain is it? sharp? stabbing? cramping?
How bad is the pain?
He has never had this type of pain before.
It says it does radiate a little on each side, but is substernal.
He said it feels like a strong pressure and that he can't breathe.
He describes the pain as a 8/10
Does anything make the pain better or worse?
What is his past medical history like?
Does he have any family history of heart disease?
When did he last eat?
Ix - obs and 12 lead ECG including V4R, right sided or posterior leads as appropriate?
Does physical exam reveal anything? lung sounds? heart sounds? JVP?
PDx - myocardial ischaemia until proven otherwise
DDx - MSK pain, spontaneous pneumothorax, trauma, PE, chest infection, pneumomediastinum, AAA, acute ventricular aneurysm, acute valve rupture, pericarditis/myocarditis, epigastric pain, GERD
He hasn't done anything he called as soon as it started really hurting, He said it started a couple of days ago, but has gotten worse over the time period. He had a gravy biscuit for breakfast (It's now 11:30.) His father had one heart attack. 12 lead reveals no ST elevation/depression or T wave depression, Posterior and Right sided are performed with the same result.
Lung sounds are clear, heart sounds are noted with S1 and S2 with no gallop or murmurs. No JVD.
He states that he has had heartburn before, but this is not heartburn, this is presenting differently.
What else would you like to do for assessment?
Pt HX , eval , vitals, orthostatic BP, quick 12 lead while stretcher/ stair chair is being brought in
325 mg ASA if no contraindications , O2, IV access, NTG if indicated,& not taking the magic blue boner pill, put his butt on the stretcher, get in the office and start heading towards definitive care while doing all the above. We have a thirty minute ride to small hospital and hour plus to cath lab if determined by diagnostic review and evaluation.
Today with the weather might take a couple hours due to whiteout conditions just to get to the local hospital.
If your in the big city with a cardiac center on almost every street corner. stay in the house and play with all the toys as your transport time is only three minutes.
You have IV access with blood drawn (if per your protocols), 12 lead performed without ST or T wave depression or elevation. Vitals remain stable throughout the orthostatics. VItals are as follows: B/P= 182/110 HR= 120, SpO2= 98 RA, ETCO2= 40. No contraindications to ASA or NTG. Both given without any relief, but now he has a headache.
What do you want to do next now that your transporting?
pericardit......awww screw it.
Quite possibly, continue assessing.
Erectile dysfunction pills are not a contraindication to GTN here, just a warning that it is prudent to give a reduced dose i.e. 0.4 mg SL instead of the usual 0.8 mg
If there was no very strong evidence as to an alternate, non cardiac cause I would give him aspirin.
Entonox +/- morphine as required for analgesia.
Serial 12 leads
Transport to the hospital
As listed above, 12 leads show no abnormalities. You have administered Morphine and the patient states that his pain has decreased from an 8/10 to a 6/10. What's next?