Jaymazing Posted January 22, 2013 Share Posted January 22, 2013 Bare with me, this is my first time presenting a scenario on EMTCity. I will begin the presentation with a brief summary of chief complaint, dispatch info, and on-arrival info. Everything else, just ask and I'll provide (to the best of my ability). You are working for a rural service, about 90 minutes away from the city, with one ALS ambulance and one BLS ambulance. It's 10:45 AM on a moderately warm spring day, and you're called to a rural address about 20 minutes away for a 54 year old male complaining of "Chest discomfort". Due to response time and location, the local fire dept is called for first response, and upon your arrival you find a well-kept home amidst a quiet farming community. First responders are on scene already, and several of them are standing around and waiting for the all-clear to go home. Your patient is a middle-aged man, sitting on a step in his garage. His wife and a fire-fighter are standing around him. He appears pale and diaphoretic, but is in no obvious distress. Upon seeing you, he sighs deeply and drops his head down; the wife tells you that she's the one who called, and her husband is does not want to go to the hospital. You introduce yourself, and find out that your patient was working around the yard when he developed some moderate chest discomfort. He had to come inside and sit down, at which point his wife noticed that he appeared "off", so she called 9-1-1. He can't describe the discomfort, he just gestures in a circular manner around his mid-chest. "I'm not going anywhere," he says when he see's one of the fire-fighters wheeling over your stretcher. You take it from here. Link to comment Share on other sites More sharing options...
Kiwiology Posted January 22, 2013 Share Posted January 22, 2013 (edited) 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? 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 If he doesn't want to go nowhere then that's fine by me, a competent patient has the right to refuse treatment, including life saving treatment, put big green pack and monitor back in ambulance, get in ambulance, drive home, done. Edited January 22, 2013 by Kiwiology Link to comment Share on other sites More sharing options...
Jaymazing Posted January 22, 2013 Author Share Posted January 22, 2013 Has he ever had pain like this before? "Sort of, I had a bit of it last week when I was mowing the lawn" Does the pain go anywhere apart from in his chest? "Nah, it's not pain. It's just...unpleasant. And it's right here" *Gestures a wide circle around his sternum* What type of pain is it? sharp? stabbing? cramping? "It's not pain. It's just like, almost a squeezing feeling. But it's not pain" How bad is the pain? "It's not that bad. It was worse earlier" Does anything make the pain better or worse? "Last time, sitting down made it go away. Today, it's going away but it's taking a long time" What is his past medical history like? "I don't like doctors, and they don't like me" Does he have any family history of heart disease? "My dad died at 60. We don't know why" When did he last eat? "Breakfast. Bacon and eggs. What does that matter? It's not like I'm on a diet" Ix - obs and 12 lead ECG including V4R, right sided or posterior leads as appropriate? ***ECG to be attached below. Sorry, no posterior leads to share**** Does physical exam reveal anything? lung sounds? heart sounds? JVP? Physical exam reveals pale, diaphoretic throughout, weak/irregular radial pulses, No trauma, abdo soft/nontender, denies N/V, No JVD, Lung sounds clear to all fields, and unfortunately I do not remember the heart sounds (or if we even listened to them). The rest of the physical exam was unremarkable 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 If he doesn't want to go nowhere then that's fine by me, a competent patient has the right to refuse treatment, including life saving treatment, put big green pack and monitor back in ambulance, get in ambulance, drive home, done. The initial 3-lead and 12-lead http://sphotos-e.ak.fbcdn.net/hphotos-ak-ash3/543912_10152476395670026_152314773_n.jpg Link to comment Share on other sites More sharing options...
Kiwiology Posted January 22, 2013 Share Posted January 22, 2013 My diagnosis is now exertional angina until proven to be otherwise His ECG possibly shows some inferior ST depression however eh, its so-so I'd like to give him some GTN and see what that does to the ECG as well as his pain; if he feels significantly better with the GTN and/or his ? ST depression completely resolves but then comes back or post-GTN he feels the same pain then I'd repeat it; but if after 2 sprays of 0.8 mg GTN it has little or no effect I would not give any more. What is his take on being transported to the hospital, still doesn't want to go? Link to comment Share on other sites More sharing options...
scubanurse Posted January 23, 2013 Share Posted January 23, 2013 BP? O2? Throw a NRB on him and see if that helps... hesitant to give NTG unless I can get him to go... Tell him he's having unresolved CP that could be an MI and he could die at home and does he want to do all that to his wife....blah blah Definitely would liket o see him go to a cath lab hospital if possible... If he consents to going NTG, ASA, O2, Morphine if we have it (4mg) if not 100mcg Fentanyl, monitor and transport... Link to comment Share on other sites More sharing options...
Jaymazing Posted January 23, 2013 Author Share Posted January 23, 2013 My diagnosis is now exertional angina until proven to be otherwise His ECG possibly shows some inferior ST depression however eh, its so-so I'd like to give him some GTN and see what that does to the ECG as well as his pain; if he feels significantly better with the GTN and/or his ? ST depression completely resolves but then comes back or post-GTN he feels the same pain then I'd repeat it; but if after 2 sprays of 0.8 mg GTN it has little or no effect I would not give any more. What is his take on being transported to the hospital, still doesn't want to go? His wife puts up a pretty convincing argument, and convinces him to go with you to get checked out. "He really doesn't look like himself," she says. Her concern is far greater than her husband's. You get him on the stretcher and give him a spray of nitro. He says it really didn't change anything, and his condition remains unchanged. A second strip is acquired a few minutes after the spray. http://sphotos-d.ak.fbcdn.net/hphotos-ak-ash3/150955_10152476975420026_1883202180_n.jpg http://sphotos-b.ak.fbcdn.net/hphotos-ak-ash4/314134_10152477061830026_13020943_n.jpg Would you like to continue nitro Tx? Any other treatments you'd like to consider? and would you deem this a "hot transport" or a "cold transport"? It's a 20-30 minute transport to the closest rural hospital, and 90-100 minutes to the city, where there's PCI capabilities. Link to comment Share on other sites More sharing options...
Happiness Posted January 23, 2013 Share Posted January 23, 2013 Sounds like a call I did but was a 79 yr old female. Treated as cadiac ended up as a hernia around the chest cavity, near the heart. 1 Link to comment Share on other sites More sharing options...
Jaymazing Posted January 23, 2013 Author Share Posted January 23, 2013 (edited) BP? O2? Throw a NRB on him and see if that helps... hesitant to give NTG unless I can get him to go... Tell him he's having unresolved CP that could be an MI and he could die at home and does he want to do all that to his wife....blah blah Definitely would liket o see him go to a cath lab hospital if possible... If he consents to going NTG, ASA, O2, Morphine if we have it (4mg) if not 100mcg Fentanyl, monitor and transport... BP is 114/76, and his Sp02 on room air is 93%. You throw on an NRB, and his sats go up to 95%. His wife starts crying as soon as you bring up the possibility of dying, and he decides he'll go "because now I'm an as**ole, apparently". You get him on the stretcher and wheel him to the ambulance. One spray of Nitro is given, with ASA PO chewed, but he refuses all narcotics. See above for further ECG's It's a 20-30 minute transport to the closest rural hospital, and 90-100 minutes to the city, where there's PCI capabilities. Edited January 23, 2013 by Jaymazing Link to comment Share on other sites More sharing options...
Happiness Posted January 23, 2013 Share Posted January 23, 2013 Sounds like a call I did but was a 79 yr old female. Treated as cadiac ended up as a hernia around the chest cavity, near the heart. Link to comment Share on other sites More sharing options...
scubanurse Posted January 23, 2013 Share Posted January 23, 2013 I'd like to give him a good fluid bolus The ekg is looking like a base of atrial flutter in leads 2 & 3 and V5 V3 is making it look kind of like a low/lateral wall infarct with early repolatization... but I tend to suck at 12 leads so I may be completely off at this one... Either way some fluid would be good and transport with a possible helo ride waiting for transfer to the city ? Link to comment Share on other sites More sharing options...
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