Chest Pain Assessment 1

Chest pain
Onset [text] prior to evaluation
Onset while: [text]

Associated Pain
Location: [text]
Radiation: [text]
Severity now: [text]
Duration: [text]
Characterized as: [text].

The pain is relieved with [text]
[select value="no|YES"] <-- OTC NSAID's
[select value="no|YES"] <-- Rest
[select value="no|YES"] <-- exertional pain
[select value="no|YES"] <-- pleuritic pain

The pain is worse with [text]
[select value="no|YES"] <-- supine or leaning forward ( concern for pericarditis)
[select value="no|YES"] <-- Rest
[select value="no|YES"] <-- exertional pain
[select value="no|YES"] <-- pleuritic pain



Associated Symptoms:
[select value="no|YES"] <-- nausea/vomiting
[select value="no|YES"] <-- diaphoresis
[select value="no|YES"] <-- shortness of breath

Pertinent PMH
[select value="no|YES"] <-- Coronary Disease
[select value="no|YES"] <-- Cerebrovascular disease
[select value="no|YES"] <-- Diabetes Mellitus
[select value="no|YES"] <-- Peptic Ulcer or GERD
[select value="no|YES"] <-- Chest injury or overuse
[select value="no|YES"] <-- ETOH use


Pt does not have recent prolonged travel, recent trauma, hypercoagulable state, hormonal therapy or hx of blood clots in the family.


Cardiovascular risks are reviewed as follows:


[select name="Q1" value="no=0|YES=1"] <-- Male 55 years or over/Female 65 or over
[select name="Q2" value="no=0|YES=1"] <-- Known CAD or cerebrovascular disease
[select name="Q3" value="no=0|YES=1"] <-- Pain not reproducible by palpation
[select name="Q4" value="no=0|YES=1"] <-- Pain worse during exercise
[select name="Q5" value="no=0|YES=1"] <-- Patient assumes pain is cardiogenic
Score --> [calc value="score=(Q1)+(Q2)+(Q3)+(Q4)+(Q5)" memo="score"] out of 5. Interpretation --> [calc value="score=(Q1)+(Q2)+(Q3)+(Q4)+(Q5);score>3?'High (62.7%) risk, proceed with ACS evaluation.':score>1?'Moderate (12.1%) risk, obtain ECG and proceed with ACS or other evaluations as indicated.':'Low (0.6%) risk, if no other indication of cardiac cause, evaluate for non-cardiac causes.'" memo="interpretation"]
[checkbox memo="display/hide references" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"]
reference: AAFP Point-of-Care Guide at [link url="http://www.aafp.org/afp/poc" memo="Ebell (2011) Am Fam Physician 83: 603-5"][/conditional]



Pt denies fever, diaphoresis, rash, palpitations, dyspnea, orthopnea, PND, cough, sputum, hemoptysis, abdominal pain, nausea, vomiting, dysphagia, syncope, lower extremity pain.

Differential: Heart/ vascular: Angina MI Acute pericarditis Aortic dissection Lungs: Pneumonia PE Pneumothorax. GI: GERD Peptic ulcer disease Pancreatitis Diffuse esophageal spasm. Other: Costochondritis Rib fracture Anxiety Herpes zoster Skin lacerations Muscle strain.

Objective:
vitals = all normal
Pt in distress - flushed face, gripping chest with hand.
No Anemia clinically; No Cyanosis; No Lymphadenopathy; No edema
ENT: Ears normal,, Nose & Mouth assessment normal
CVS: S1=S2, No S3/4, RRR, no murmurs heard
Resp: No distress, GAEB , widespread coarse crackles throughout both lungs, no wheezes
DERM: No rash, Normal exam
MSK: Lt upper pectoralis major muscle area is tender to deep touch

Initial ECG normal
2nd ECG- ST suppression in inferior leads.
3rd ECG- continuous ST depression inferior leads with inverted T vaves
Initial troponin measurment- 50-100 positive
Rest of initial bloodwork = all normal

Assessment:
call out ER visit - Non-STEMI (consider Unstable angina over weekend, inferior ischemia today).

CC- 19:00 - 20:15 pm

Critical care - first 30 min 7:00 - 7:30 pm - 5 min attendance to other pot from 7:20-7:25 pm
- continuous ECG monitoring
- STEMI protocol

Critical care - second 30 min 7:30 - 8:00
- continuous ECG monitoring
- STEMI protocol

Critical care - third 30 min 8:00 - 8:25 - medical student monitored and I reviewed ECG's and referred pt
- continuous ECG monitoring
- STEMI protocol

Crisis intervension 20 min - discussion with pt and wife - explained condition in detail - discussed treatment now and possible treatment options later, including probable referral to vancouver for angiogram - pt settled after initial anxiety and stress reaction

Urgent specialist consult with Internist at UNHBC on call, Dr - he referred to ER physician and agreed with treatment approach

Urgent ER physician consult at , Dr = he accepted unconditionally - agreed with treatment, not to give TNK at this time

Urgent tel consult with PTN - Dr , RN's and - accepted stat transfer - nurse to accompany pt with transfer

Plan:

1) NSTEMI/UA protocol initiated
- 325 mg ASA stat po given in ER
- Nitro patch 0.4mg SC
- Metoprolol 25 mg PO STAT and q12hrs
- Clopidegrel 300mg PO STAT
- Atorvastatin 80 mg PO STAT
- Enocaparin 72mg SC STAT, then qrn
- Morphine sulfate 2.5 mg IV q15min prn
- Saline lock in place

2) Transfer to