Objectives By the end of this module, you should be comfortable: Providing a list of the critical diagnoses to consider in a patient presenting to the ED with chest pain Discussing the differences in the initial assessment, workup, treatment and disposition for these critical diagnoses Preparatory Work Before continuing, read the following: Approach to
Case 1 Presentation: 42 year old female presents with fatigue and chest pressure that began several days ago. She has noticed extreme fatigue while working in her garden, and today developed chest pressure and shortness of breath. History of HTN, DM, and tobacco abuse. BP 105/58 HR 60 RR 18 SpO2 93% RA Temp 98 PE: alert, ashen, diaphoretic; heart RRR, lungs clear and equal, no JVD, no peripheral edema As you walk to the room, a list of the critical diagnoses you need to address for a patient of this age, sex and chief complaint should pop into your head. List them here in order of likelihood for this patient. 1 2 3 4 5 6 7 Workup What are the most important initial orders and why? While you re waiting for those tests, what initial stabilizing interventions would you order in this patient?
The following diagnoses should be on your differential of chest pain in the ED. Take some time to read about them. Thoracic Aortic Dissection Pneumothorax Acute Heart Failure Pulmonary Embolism Peridcarditis Here is your patient s ECG. Interpret this ECG. What is your very next step?
Interpret this CXR. Any additional stabilization measures or treatments in the ED? If the findings on the EKG were not present (i.e., normal EKG), what presumptive diagnosis would you give this patient? How would a patient with that diagnosis be initially treated and worked up? What if your CXR looked more like this...
Interpret this CXR. How would a patient with that diagnosis be stabilized and what is the disposition?
Case 2 Presentation: 38 y/o previously healthy male with sharp central chest pain. It is worse with inspiration and slightly better when leaning forward. It is worse with slight exertion and he has increased dyspnea with exertion. BP 134/76 HR 113 RR 21 SpO2 96% RA Temp 100.2 PE: alert, uncomfortable, heart RRR, muffled heart sounds, no murmurs but there is a slight friction rub, breath sounds equal and clear, no JVD, no edema As you walk to the room, a list of the critical diagnoses you need to address for a patient of this age, sex and chief complaint should pop into your head. List them here in order of likelihood for this patient. 1 2 3 4 5 6 7 Workup What are the most important initial orders and why? While you re waiting for those tests, what initial stabilizing interventions would you order in this patient?
There are several findings on the ECG suggestive of the diagnosis. Name them, interpret the ECG and provide the diagnosis. What is the typical evolution of ECG findings for this diagnosis?
Case 2 Reassess: You go in to inform the patient of your brilliant diagnostic skills, and you find him diaphoretic, pale, and very dyspneic BP 74/45 HR 125, RR 30 SpO2 94% RA PE: really uncomfortable, distant murmurs + JVD You astutely recognize this rare but life-threatening complication... What are some other complications of this diagnosis? What bedside test will confirm your suspicion? What procedure does this patient need emergently?
Whew. You saved him! What is your disposition for this patient? Wait...you were just dreaming of an awesome shift. That didn t actually happen. Instead you go back to reassess the patient and he is feeling better. Just to be sure, you do a quick bedside ultrasound... Now (in this much more common scenario) what is the treatment and disposition of this patient?
Case 3 Presentation: 24y/o male brought in by EMS after a syncopal event. He has been coughing for several days and passed out after a big coughing episode today. He now has sharp left sided chest pain, worse with inspiration and coughing. BP 123/79 HR 114 RR 21 SpO2 95% RA Temp 97.8 PE: alert, comfortable, heart RRR w/o murmurs, possibly diminished lung sounds on the left, exam otherwise normal As you walk to the room, a list of the critical diagnoses you need to address for a patient of this age, sex and chief complaint should pop into your head. List them here in order of likelihood for this patient. 1 2 3 4 5 6 7 Workup What are the most important initial orders? While you re waiting for that test, what initial stabilizing interventions would you order in this patient?
Interpret this ECG and CXR. What is the diagnosis and management of this patient? Finally, complete the DIEM case by clicking below. DIEM