# 34 y/o female with chest pain



## Ewok Jerky (Jul 18, 2014)

OK this one is NOT for all you veterans out there.  Its not tricky, and not obscure, but my hope to help some relatively new peeps how to assess a Pt.  I want to know what you are thinking and why, what is your differential and how can you narrow it down to a working diagnosis?

You work in a medium sized suburban town with several area hospitals.  It is 0830 and you are dispatched for 34 y/o F with chest pain.  You arrive on scene to a 2-floor residence in a densly populated, middle class development.  You walk inside to find the Pt lying on the couch wearing a hoodie and a blanket over her body.  Her (presumble) husband is in the room with a newborn child in his arms. 

What are you thinking? What are your primary concerns?  What more info do you need?

*if you already know what her pathology is don't just post it, let someone else think it through for themselves!


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## STXmedic (Jul 18, 2014)

It's lupus.


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## medichopeful (Jul 18, 2014)

Could you describe the pain, how long it's been going, and the location(s)?  Any difficulty breathing?  Any cough?  Any pain on coughing or movement, or any pain anywhere else?  Also, when was the child born? (past week?  Past hour?) Any complications, both with birth and pregnancy?  If it was recent, how was the child born, and how much blood loss?  Is there still bleeding?  Moving on a little bit from that, what are the patient's vitals (including temperature)?

There's more I want to know, but we'll start with that!


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## Ewok Jerky (Jul 19, 2014)

medichopeful said:


> Could you describe the pain, how long it's been going, and the location(s)?  Any difficulty breathing?  Any cough?  Any pain on coughing or movement, or any pain anywhere else?  Also, when was the child born? (past week?  Past hour?) Any complications, both with birth and pregnancy?  If it was recent, how was the child born, and how much blood loss?  Is there still bleeding?  Moving on a little bit from that, what are the patient's vitals (including temperature)?
> 
> There's more I want to know, but we'll start with that!



Good questions. I think you might be on to something.  

Pain is localized on the left anterior.  No difficulty breathing, +cough, pain is exacerbated with deep breaths.  She also has pain from her surgical site, c-section.  baby was born 5 days ago via c-section, mom was was in the hospital 4 days for recovery and came home yesterday.  EBL-50cc.  No bleeding.  

Vitals: T98.6 HR90 RR18 BP118/76 O298% ra

-if you got it so far, maybe I made this too easy...if not what's your differential? What are you concerned about?

-the community hospital that performed her c-section is 10 minutes away
-Level 1 trauma center with cath lab is 20 minutes away


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## Maddog1d (Jul 19, 2014)

Complications during the procedure? Medications? onset of pain? pain on palpation? Id still like to know LOC, GCS, glucose, and get a 12 lead.

Possible cardiac, Possible PE (but no SOB), orrrr chest hurts bc of the coughing haha

O2, IV, Monitor for now


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## Ewok Jerky (Jul 19, 2014)

Maddog1d said:


> Complications during the procedure? Medications? onset of pain? pain on palpation? Id still like to know LOC, GCS, glucose, and get a 12 lead.
> 
> Possible cardiac, Possible PE (but no SOB), orrrr chest hurts bc of the coughing haha
> 
> O2, IV, Monitor for now



No complications. She is only taking 5mg oxycodone for post-surgical pain. Chest pain started this morning when she woke up about 1.5 hours ago. No pain on palpation. She is alert and oriented x3, GCs 15, glucose 78.  12-lead shows sinus tach.

What else could help you, as a prehospital provider, rule in/out cardiac, pe, or pleuritic pain?

She wants to to the community hospital, are you comfortable with that?


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## chaz90 (Jul 19, 2014)

Signs of right ventricular strain on the EKG? Lung sounds? Does she smoke? I'm leaning towards a PE but the jury remains out.


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## Ewok Jerky (Jul 20, 2014)

chaz90 said:


> Signs of right ventricular strain on the EKG? Lung sounds? Does she smoke? I'm leaning towards a PE but the jury remains out.



There may be some ST-depression in V1 and V2, hard to tell.  Lung sounds are clear bilaterally.  She stopped smoking when she found out she was preganant with a 8-packyear history.

What are her risk factors for and MI? (clue: no one asked)
What are her risk factors for PE?


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## drl (Jul 21, 2014)

beano said:


> What are her risk factors for and MI? (clue: no one asked)
> What are her risk factors for PE?



Newbie here, but interesting scenario, so I'll give it a try.

My best guess given all the information so far would be PE; the C-section + being in bed during recovery would increase her risk for that I think.

Relatively young patient, so an MI would be rare. Is the patient obese? Any history of diabetes? Any history of alcohol/drug use?


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## Angel (Jul 21, 2014)

MI in a patient this young is rare but don't be so quick to rule it out. I've had a patient the same age was having an inferior MI and I almost cast her pain away as pleuritic


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## Handsome Robb (Jul 21, 2014)

Can we see a copy of the 12-lead by chance? 

The "worst" MI patient I had was a healthy, 37 year old male that had 6 separate VT arrests plus a few episodes of sustained pulsatile VT that bought him cardioversions in the 40 minutes I spent with him.

I've got a pretty good idea of her problem but I'll leave it alone as the OP asked.


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## rmabrey (Jul 21, 2014)

I also have a good idea where you're going with this but ill let it go as well.


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## PotatoMedic (Jul 22, 2014)

I'm thinking adhesion of the pleural space.  Recent surgery can cause issues.  Not thinking PE since no SOB resp issues.  Not thinking pluritis because no fever or elivated bgl.  Not thinking cardiac because pain changes and EKG is stated to look clear.  I would transport to community hospital since pt seems stable with info provided and that is where she had her surgery and I am not thinking of anything that may need a catch lab.  

Who knows... I could be completely wrong.  (Probably am)


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## Anonymous (Jul 23, 2014)

sooooo


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## Ewok Jerky (Jul 25, 2014)

Sorry yall, I been working 17-hour days on my rotation and the last thing I want to do is surf the net.  

It turns out it WAS lupus. Go figure.

No it was PE.

My point of this senerio was to think about risk factors, and how your questions regarding medical Hx and HPI can guide you to a likely Dx.  I think in EMS we get very comfortable with physical exams but not a complete History and Physical.

Risk Factors for PE
-Hx of DVT
-pregnancy
-recent surgery
-oral contraceptives (or estrogen hormone therapy)
-cancer
-and of course thrombophilias

Risk Factors for MI (there are many but the big ones you can ask about)
-smoking
-high cholesterol
-HTN
-diabetes
-family Hx of MI or stroke before age 55ish
-lets just say "lifestyle"


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## drl (Jul 27, 2014)

Thanks for sharing, beano. Interesting scenario!


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## Anonymous (Jul 28, 2014)

Great post Beano. When you get a little more time I would love to see more posts like this one.


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