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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?

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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?

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