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Sticking to the basics
by Patrick Lickiss

Clinical scenario: Chest pain while mowing the lawn

You respond to a 57-year-old male who felt a sudden onset of chest pressure. What is your differential diagnosis?

By Patrick Lickiss

Post your assessment in the comment section below, and the person with the best answer will receive one of our exclusive EMS1 Challenge Coins!


While parked at post, you receive a call to a private residence on a hot and humid Saturday morning. You are responding for a 57-year-old male reporting chest pain while mowing the lawn. Dispatch advises that they have prompted the patient to take aspirin and that he has taken three chewable tablets. 

In your system, BLS ambulances respond with paramedic quick-response vehicles. Your assigned QRV is clearing a cardiac arrest on the other side of town and states an approximate ETA of 20 minutes. Your mobile data terminal indicates that you are five minutes from the call. 

When you arrive on scene you walk up to the front porch of the residence where a moderately overweight man introduces himself as Frank. Frank states that he was mowing the lawn when he experienced a sudden onset of chest pressure. He says that he became sweaty and felt dizzy at the same time.

Thinking that he was just dehydrated he sat on the porch and drank a few glasses of water. When his pain did not subside, he asked his wife to call 911. 

Patient assessment

Frank has a history of high cholesterol and high blood pressure and states that his doctor has been advising him to lose weight. He has had episodes of chest pain in the past but not for a year or so.

This time the pain seems unusual. He has a prescription for nitroglycerine and has taken two tablets with no improvement in his symptoms. 

Frank reports that his pain is a six out of 10, feels like a pressure and does not radiate. Frank’s blood pressure is 172/92 with a pulse of 94 and respirations of 20. His pulse-ox is 97 percent on room air. 

You request an updated ETA for ALS and are advised 15 minutes. 

While you wait for ALS think about the following questions:

  • What is your differential diagnosis?
  • What are some “must not miss” diagnoses for this patient?
  • What are your treatment priorities?
  • What additional questions would you ask this patient?

About the author

An EMS practitioner for nearly 15 years, Patrick Lickiss is currently located in Grand Rapids, MI. He is interested in education and research and hopes to further the expansion of evidence-based practice in EMS. He is also an avid homebrewer and runner.
The comments below are member-generated and do not necessarily reflect the opinions of or its staff. If you cannot see comments, try disabling privacy and ad blocking plugins in your browser. All comments must comply with our Member Commenting Policy.
Rachel Cunningham Rachel Cunningham Thursday, August 21, 2014 7:57:43 PM ACS, most likely demand ischemia- get the 02 on him, admin a 3rd nitro and ASA if not already dosed appropriately. Id transport to closest appropriate facility without waiting for medics. He needs a cath lab not a delay for field 12 lead. Sig hx of HTN and high chol is concern enough for suspected blockage/thrombus. Id also inquire about his meds, blood thinners, BP meds and cholesterol meds and assess for compliance.
Austin Gardner-Bowler Austin Gardner-Bowler Thursday, August 21, 2014 8:35:01 PM *As a BLS unit, I would do the following per state protocol". 1. He is having trouble with his cardiac and nervous system. Possibly suggesting an MI or other cardiac issue. His chief complaint is sudden onset of pressure to the chest, secondary symptoms would support this, along with his history cardiac problems, a script of nitro, along with his description of events. 2. Some "must not miss" Dx would be: allergenic reaction, heat stroke, infection/illness, diabetic emergency. 3. My initial treatment would include O2 at 15 liters via a NRB (per national guidelines). Treat for possible shock. Verify that all 5 "R's" are intact with the prescription and administer an additional dosage or nitro per state protocol. A set of vital prior and 5 minutes after administration. Blood glucose test. All further treatment would be determined on answers given by the patient during assessment and/or found during "treatment". 4. Is he allergic to anything? Has this occurred before and when and what helped it, if applicable? When was his last oral intake prior to drinking the water on the porch? Any notable past history (diabetes, stroke, heart attack, etc). Is he currently taking any medication? Is he use to exerting this much energy at once? Has he fallen or hit his head in the last 72 hours? Any family history of diabetes, cardiac issues or other serious problems? Has his doctor ever mentioned the possibilities of diabetes, or other similar problems? (In addition to this, determining his level of consciousness/alertness, level of priority and need for additional services).
Gerry Shriver Gerry Shriver Thursday, August 21, 2014 8:46:56 PM Posable heart attack chest pain with pressure swetty pail aganal breathing have patient rest in comfortable position monitor vital signs put patient on o2 give patient additional nitro have medic meet you enrout to the hospital also put the pt on a twelve lead EKG do you have a history is chest pain or heart attack what meds are you tekeing daily on a scale of 1to 10 how bade is the pain
Greg Abegglen Greg Abegglen Thursday, August 21, 2014 8:52:47 PM IV NSA TKO, 12 lead, Nitro if local protocol allows, O2, cool him down if warm, rapid transport, monitor.
Amy Macomber Amy Macomber Thursday, August 21, 2014 9:06:56 PM I'd love to know what his EKG shows on a 12 lead. What are his meds? A full SAMPLE and OPQRST are called for in the situation. Iv, O2, moniter. Dehydration and electrolyte issues are my main worry.
Timothy Ray Timothy Ray Thursday, August 21, 2014 9:12:01 PM First I would ask frank to take a deep breath and answer wether or not it made the pain worse. Second I would ask frank to raise his arms above his head and answer wether that made it hurt worse or not. If pain increased upon movement or deep breath I would think its a pulled muscle if not i would be suspicious for acute coronary syndrome or a possible aneurism. Either way next step would be to live the patient inside to the Ac apply oxygen administer a 3rd dose of nitroglycerine and contact his pcp while waiting for ALS to arrive. Allergies and pertinent medical history would be the only other questions I would consider given its a basic unit waiting on ALS.
Sean Quinn Sean Quinn Thursday, August 21, 2014 11:09:30 PM First put the Pt on oxygen and hook him up to monitor. If possible get 12 lead EKG. Ask cardiac history, stents , bypass, previous MI's? Recent stress test? Medications? Check lung sounds,pulm edema?
Marian Macomber Marian Macomber Friday, August 22, 2014 1:18:48 AM Who are you talking about JHM III??????????????????
Marian Macomber Marian Macomber Friday, August 22, 2014 1:20:41 AM Just read the 1St. part of email, hope that is who you were talking about.
Bob Peterson Bob Peterson Friday, August 22, 2014 3:02:59 AM Differential DX without an EKG at this point is ACS. His saturations are high enough to withokd oxygen (current AHA recomendations), how are his lung sounds? As a BLS unit, contact OLMC for orders to assist this patient with his own NTG, he has already taken two, standard regimen at this point would be a single dose for a total of three unless OLMC advises differently, was his pulse regular or irregular? Where is the pain? Pinpoint pain or dispersed almost visceral pain? He has HTN as well as high cholesterol, red flags for cardiac type issues, could be however a PE... Does he have a fever? Changes in his meds? What are his meds? If a beta blocker, his sympathetic system is over-riding the blockade based on his rate. Would love to see even a strip of his rhythm at this stage, and I would want an EKG as soon as possible post contact. What are my local protocols for the ASA? He took three, perhaps a fourth for a total of 324mg. Monitor his vitals and wait for the transporting unit. We know most if not all of the OPQRST AMPLE stuff, focused exam, is the discomfort able to be reproduced with movement or palpation? Stuck without an EKG and transport options...
Zachary Isham Zachary Isham Friday, August 22, 2014 4:22:58 AM DD: ACS High cholesterol, hypertension, and a history of chest pain. If the PTs BP is 172/92 it could have been much higher. Oxygen, 4th aspirin(if not already taken), 3rd nitro with continuing to monitor vitals, and rapid transport and meet ALS enroute. If protocol allows do a 12 lead ECG. Listen to lung sounds. Does anything make it worse/better? What was it like a year ago and what was the outcome? What medications do you take and are you up to date on them? Has anyone in your family died of a heart attack? Has your activity level changed in the last couple weeks? Have you taken any illegal drugs in the past month? Have you had a fever or been ill in the last couple weeks? Do you wake up with night sweats? Are you having any difficulty breathing? When was the last time you saw your PCP? Did they do a 12 lead?
Harley Flores Harley Flores Friday, August 22, 2014 11:29:47 AM It sounds a lot like an anxiety attack. Although I'm not an ems yet I just started school to become an ems.
Jackie Sharkey Grinstead Jackie Sharkey Grinstead Friday, August 22, 2014 3:51:12 PM Wow, no ALS for 20 min. You could transport if your closer to the Hospital than the ALS can get there. Check blood sugar, keep him comfortable, get all medical history. Medication, surgeries, dx, as much detailed info you can get. It's hard to think as a BLS, my brain is ALS.
Chris Turbessi Chris Turbessi Saturday, August 23, 2014 3:15:37 AM Put the patient on o2 check to see if pain is reproducible either by inspiration or movement Check expectations date on his ntg
Chris Turbessi Chris Turbessi Saturday, August 23, 2014 3:17:35 AM Put the patient on o2 check to see if pain is reproducible either by inspiration or movement Check expectations date on his ntg if it's been a year since pain his might be expired. And what did they diagnose the last time
Robbie Wagnone Robbie Wagnone Sunday, August 24, 2014 7:54:27 PM He should hire someone to now for him.
Brian Linacre Brian Linacre Tuesday, August 26, 2014 5:15:35 PM I would ask his if the pain is worse with movement? if he had taken any drugs in the last 24 hours? What other medical history does he have? How is his breathing? along with sample and opqrst. I would start with o2 15 LPM on NRB. position him in a position of comfort and prepare to transport. i would consider the possibility of pericarditis with the pressure on the chest that improves when leaning back and the pt has a fever. i would consider cocaine with the pt presenting pressure, sweating, dizziness. priority would be to transport to the hospital asap.

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