Case #12
Pain in the Chest

Case Goals
  • Take a focused history of the chest pain
  • Order an appropriate initial workup for chest pain
  • Identify the most likely diagnosis
  • Initiate appropriate emergent management

    • Goals

  • Take a focused history of the chest pain
  • Order an appropriate initial workup for chest pain
  • Identify the most likely diagnosis
  • Initiate appropriate emergent management
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    You are working in a busy emergency department when a 55-year-old man is brought to your bay. He appears uncomfortable, mildly diaphoretic, and is clutching his chest. The triage nurse hands you his chart and says, 'He's been waiting about 20 minutes—says the pain started a couple hours ago.'

    Case Complete!

    High Yield points about this case:

    • Time is muscle: early reperfusion in STEMI improves survival and preserves myocardium—door-to-balloon time should be <90 minutes.
    • Classic ischemic chest pain is pressure-like, substernal, and may radiate to the left arm, neck, or jaw, often accompanied by diaphoresis, dyspnea, and nausea.
    • ST-segment elevation ≥1mm in two or more contiguous leads with reciprocal changes supports the diagnosis of STEMI.
    • Initial management of STEMI includes chewable aspirin (162-325mg), rapid cardiology activation for primary PCI, and consideration of nitroglycerin if no contraindications.
    • A normal chest X-ray does not exclude acute coronary syndrome or other life-threatening cardiac causes of chest pain.
    • Major cardiovascular risk factors include smoking, hyperlipidemia, hypertension, diabetes, family history of premature CAD, and sedentary lifestyle.
    • Supplemental oxygen is indicated only for hypoxemia (SpO2 <90%); routine oxygen in normoxic MI patients may be harmful.