Chest pain scenario

LucidResq

LucidResq

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Objectives:
-identify possible diagnoses
-create a plan of action
-identify possible complications and state how the provider would prepare to deal with them.

You are dispatched to the home of a 57 y/o female c/o chest pain. Her husband greets you at the door and rushes you in. He says that she's been complaining of some discomfort while breathing and mild chest pain for the past 2 weeks, but she has lung cancer so they initially didn't think there was an emergency. Today he had a bad feeling about her condition, and he says it seems there is something wrong.

He leads you to the woman, who is sitting on the couch. She looks anxious, pale, and seems to be breathing fairly rapidly. She tells you that she has a a sharp pain in the middle of her chest. It started 2 weeks ago, has been slowly getting worse, breathing and lying down worsen the pain, and it does not radiate. She says she also feels dizzy. Denies trauma or recent illness (besides the cancer).

HR - 118
RR - 15
BP - 98/56

Ask for any other assessment procedures you would like.
 
I am a basic, who just started civilian medic school.

Is she havin trouble breathing besides the pain?

I would get a pulse/ox and ECG.Place her on High flow O2.
Place her in a position of comfort.
Get lung sounds? what does she sound like?
Get IV access and Blood Sugar.
Interpret the ECG? findings?
transport her to closest facility.
Obtain a complete history including meds.

she could be experiencing pain related to her lung cancer.(increase in pain while breathing, positional pain). Possible CHF, Pulmonary edema?

Consider ASA according to protocols, no nitro due to hypotension.
Consider Albuterol/Atrovent SVN depending on lung sounds?
Possibly Lasix if she is experiencing CHF/Pulm edema problems?
 
Forgot to add my reasoning for the Albuterol/Atrovent idea. If it is possibly Bronchitis or COPD? Depends on what you get from her history? Lung cancer usually points towards other lung issues. leading up to the cancer and post treatment infections and inflamations.
 
18 lead, auscultate, percuss, tactile fremitus, beck's triad?.

Secondary survey, functional inquiry, including recent tx, other lung pathologies.

Immediate tx plan, increase FiO2 100%

The positioning change could point toward tamponade, big ticket item for any Ca pt is PE. Sure don't want to miss pneumo.

Females need a whole new study to reflect what constitutes "cardiac chest pain", differential till proven otherwise.
 
Sp02 = 95%

You now note JVD.

Lung sounds equal bilat with some rhonchi, breath sounds absent in upper right due to lobectomy.

Here's the ECG:
2007710154022445.gif


History -
COPD - 4 yrs
stage IIIA pulmonary adenocarcinoma - 1 yr

Meds/recent treatments -
right upper lobectomy 10 months ago
radiation past 8 months
Chemo: Cisplatin, Vinblastine.
Atrovent, albuterol. Took two puffs of albuterol an hour ago.

Percussion notes are normal and symmetrical. Fremitus is decreased.
 
right sided hart failure?
Tamponade?

I am not that skilled in ECG interpretation, only starting to look at that on my own, we don't cover it in class for several more months, but looks like a sinus rythym with depressed ST segment or missing a T wave all together?
 
I forgot to mention that heart sounds are muffled / distant.

The ECG shows "electrical alternans"

(sorry if I'm not much help, I'm a basic student)

She has lymphatic cardiac tamponade caused by the adenocarcinoma. Great job guys. :)
 
Last edited by a moderator:
first of all i want to start this patient on o2 ( 5-lpm to be exact with a nasal cannula) get this patient on a monitor...12 lead that is. it shows that her HR is tachycardia but her b/p shows hypertensive. try starting some nitro via iv push? see how she reacts, blast the heat in your bus. transport rapidly with head elevated and re-assess vitals everyy 15 or so
 
YouthCorps1 said:
first of all i want to start this patient on o2 ( 5-lpm to be exact with a nasal cannula) get this patient on a monitor...12 lead that is. it shows that her HR is tachycardia but her b/p shows hypertensive. try starting some nitro via iv push? see how she reacts, blast the heat in your bus. transport rapidly with head elevated and re-assess vitals everyy 15 or so
Click to expand...

you really dont have the foggiest clue about what your talking about do you?
 
This is acutely making me laugh tonight!
 
YouthCorps1 said:
first of all i want to start this patient on o2 ( 5-lpm to be exact with a nasal cannula) get this patient on a monitor...12 lead that is. it shows that her HR is tachycardia but her b/p shows hypertensive. try starting some nitro via iv push? see how she reacts, blast the heat in your bus. transport rapidly with head elevated and re-assess vitals everyy 15 or so
Click to expand...

[YOUTUBE]http://www.youtube.com/watch?v=wKjxFJfcrcA[/YOUTUBE]
 
Is it a MI? Ive been taught if chest pain worsens with breathing chances are it isnt cardiac. My computer doesnt wanna show the 12 lead :(
 
YouthCorps1 said:
first of all i want to start this patient on o2 ( 5-lpm to be exact with a nasal cannula) get this patient on a monitor...12 lead that is. it shows that her HR is tachycardia but her b/p shows hypertensive. try starting some nitro via iv push? see how she reacts, blast the heat in your bus. transport rapidly with head elevated and re-assess vitals everyy 15 or so
Click to expand...

I ask as someone who knows nothing about your system but, can cadets(who i understabd to be kids, could be wrong) do a 12 lead and IV,
 
What's the fascination with the heat in the rig?

If this is a cancer pt. I'm going to want to know her code status right away. It may be just for comfort measures.
 
Sasha said:
Is it a MI? Ive been taught if chest pain worsens with breathing chances are it isnt cardiac. My computer doesnt wanna show the 12 lead :(
Click to expand...

Try pressing down on the heart area.. if this makes the pain worse, it's probably not cardiac related, more likely an anxiety problem. However, cant rule anything out without the 12 lead.
Try nitro, ASA, O2 (4lmp NC) and blah blah blah... typical cardiac protocols.
 
Can you define Hypertensive?


Nitro by IV Push?

Let's talk like some of my preceptors talk to me when I want to give a drug.

What's nitro?
how does it work?
What is the dose(s) and route(s) for the medication?
What are the effects of nitro?
Side effects?


Why 5lpm of O2? My regulator has a 4 and a 6.


Finially... if you really think the patient is sick.... why are you only re-assessing vitals every 15 minutes?
 
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