EKG case: Why is a two-week chest pain complaint now an emergency?

What's your assessment and care for a patient who has had two weeks of persistent chest pain?


Article updated July 30, 2017

EMS providers are often presented with patients who neglect their health status, whether they are aware of it or not. Often times, patients present with vague symptoms that may be discounted by EMS providers as not meritorious of EMS activation, in favor of less acute and more common diagnoses. However, prehospital providers are still responsible for performing an adequate patient evaluation. The importance of a thorough physical examination can never be over-emphasized. 

Patient presentation: Several days of chest pain

You are dispatched at 6 a.m. to the house of a 54-year-old male with a chief complaint of chest pain. Upon arrival, you are greeted by the patient's wife and a mildly obese patient who is seated in the living room.

Primary assessment:

The seemingly undistressed patient welcomes you and expresses regret at his wife’s activation of EMS for what seems to be, for him, an irrelevant complaint of chest discomfort over the past few days. The wife interjects that the patient's pain began with an acute episode of diaphoresis and breathing difficulty approximately two weeks ago. The symptoms partially subsided after a couple of hours, but have persisted with varying intensity since then.

She adds that the patient complained of having difficulty breathing while in bed during the previous night, thus prompting her to call 9-1-1, knowing her husband's usual apathy for health examinations.

Patient's vital signs: 

Heart Rate: 95 bpm
Respirations: 16 rpm
Blood Pressure: 138/68 mm Hg
SpO2: 98 percent room air
Pain: 5/10

Past medical history:

None. Patient's wife reports that the patient is always reluctant to visit his primary care provider and any other form of health care evaluation.

Allergies:

No known drug allergies 

Meds: 

None

Upon questioning, your patient tells you that the pain radiates to the left side, is alleviated when sitting, is sharp and increases with deep breathing. Your partner prepares to record a 12-lead EKG, while you start an IV line.

Initial EKG (click for larger image):

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Above is the 12-lead EKG that you are given. The computed interpretation is:

HR 90
PRI 162
QRSd 84
QT/QTc 324/400
Paxis 59
QRSaxis 33
Taxis -7

It reads:
Normal Sinus Rhythm
Left Atrial Hypertrophy
Abnormal QRS
Inferior MI
Possibly recent

Remember to complete your own interpretation of the 12-lead EKG using the steps recommended by the EKG Club.

Initial patient treatment

You explain to your patient that the symptoms he experienced two weeks ago and the current chest pain could be related and will require further evaluation in the emergency department. He reluctantly agrees with your advice to go to the hospital.

You begin by administering one SL nitroglycerin tablet, and 325 mg of chewable aspirin, per your chest pain protocol, and prepare for transport to your local hospital, which happens to be a regional PCI facility. The treatments do not improve the patient’s symptoms during transport.

Patient response to treatment:

You proceed to carry out an uneventful transport and eventual transfer to the emergency department. Consider these questions about the patient's condition and best course of treatment. 

  • What do you think is causing the patient’s pain, beginning two weeks ago at its onset?
  • What do you think is happening now?
  • After two weeks of symptoms, is this now an urgent case?

Patient follow-up: Why a 12-lead EKG, patient history are needed to make a diagnosis 

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