- Jon Teegardin
When assessing the patient with chest pain, it is important to pay attention to all of the information available from the patient. Not all chest pain is related to cardiac issues, and not all incidents of myocardial infarction present with classic chest pain symptoms. There are many possible causes of chest pain. The source of chest pain can be cardiac, respiratory, muscular, gastro-intestinal, or even psychological. This paper will discuss several causes of chest pain, and then address cardiac, circulatory, and respiratory assessments of a patient with a chief complaint of chest pain.
Causes of chest pain
Myocardial infarction or heart attack results when a blood clot disrupts the flow of blood to the heart muscle itself (Jarvis, 2012). Patients often describe a crushing, heavy feeling in the chest. Sometimes the pain radiates to the jaw or left arm. The pain can hit suddenly or build gradually. This type of pain is not reproducible and isn’t relieved by nitroglycerine.
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Angina is chest pain caused by a buildup of plaque in the arteries that supply the heart with blood. It is described as a tightness, squeezing, or burning in the chest. It can last anywhere from five to thirty minutes and can occur when the heart is working harder or when it is at rest (Jarvis, 2012). Angina is typically relieved with rest and medication.
Aortic dissection occurs when the inner layers of the aorta separate. The pain occurs suddenly and is described as sharp, stabbing, or tearing in nature in the chest or back. The pain is not relieved by rest or medication and is a medical emergency that requires surgical intervention.
Digestive causes of chest pain include heartburn, gallbladder, and pancreas issues. This type of pain is described as pain or burning in the epigastric area and is relieved by antacids, dietary changes, or pain medication.
Chest pain can be associated with injury to the muscles and cartilage in the chest. An inflammation of the cartilage of the rib cage, known as costochondritis can cause pain. Sore muscles from overexertion or bruised and broken ribs can cause chest pain as well. These types of pain are reproducible and are not relieved by nitroglycerine.
Chest pain related to respiratory problems include blood clots in the lung called pulmonary embolism that cause shortness of breath and chest pain. Pleurisy, which is an inflammation of the membrane covering the lung causes chest pain that is worse when coughing or inhaling. Pulmonary hypertension can also cause chest pain.
The patient is a 56 year old male that arrives at the emergency room by EMS transport with a complaint of chest pain that began one hour ago. The patient also complains of shortness of breath, and is sweating profusely. EMS has initiated IV access, placed the patient on 2 liters per minute of oxygen, given 325 milligrams of aspirin, and given one sublingual 0.4 milligram nitro. A focused assessment is started.
The patient is asked to describe his chest pain and what he was doing when the pain started. The patient reports that he was doing yard work when he became short of breath and started sweating profusely. He felt a crushing pain in his chest and the pain went up the left side of his neck into his jaw. The patient coughs several times while giving this information. He describes the pain as a crushing feeling in his chest. He also states that his left calf has been hurting for several days, but thinks it’s just muscle cramps.
Vital signs are obtains and are as follows: Blood pressure is 189/98, pulse is 140 beats per minute. Respirations are labored at 24 per minute. O2 saturation is 95% with two liters per minute of oxygen applied by nasal cannula. The patient’s heart sounds are auscultated and normal S1 and S2 are noted. The apical pulse is bounding and tachycardic at 140 beats per minute. The lungs are auscultated and decreased breath sounds are noted in the right lower lobe. Crackles are noted bilaterally in the lower lobes as well.
The brachial pulses are palpated bilaterally by pressing the artery against the bone on the anterior medial aspect of the right and left elbow (Jarvis, 2012). The pulses are strong and equal. The radial pulses are palpated bilaterally by again pressing the artery on the posterior medial aspect of each wrist. These pulses are also strong and equal. Turgor is assessed on each upper extremity by pinching a small fold of skin on the back of the hand. No tenting is observed. The color of the extremity is pink and feels warm to the touch. Capillary refill is assessed by pressing down on the fingernails of each hand and observing the blanching. The capillaries refill in less than 2 seconds. Next the lower extremity pulses are assessed. The femoral pulses are palpated by pressing deeply into the medial aspect of the upper thigh, below the inguinal ligament and about midway between symphysis pubis and anterior superior iliac spine (Jarvis, 2012). Two hands are used, one on top of the other to feel the femoral pulse on each leg. The pulses are even and regular. Moving down the lower extremities, the popliteal pulses are palpated by pressing down on the posterior medial aspect of the knee. The left pulse is slightly diminished compared to the right pulse. Next the posterior tibial pulses are palpated. The posterior tibial pulses are located on the posterior aspect of the ankle. Again, the left pulse is diminished significantly compared to the right pulse. Finally, the dorsalis pedis pulses are palpated on the top of each foot. The left pulses amplitude is low, the right pulse is normal. The left calf is warm and swollen compared to the right calf. The patient complains of pain when the left calf is palpated. Turgor is assessed on the top of each foot and no tenting is observed. Capillary refill is brisk and less than two seconds on the right foot, but is sluggish in the left foot. Decreased pulses in the lower left extremity, swelling and pain are indicative of a blood clot known as a deep vein thrombosis (National Institute of Health, 2011).
S: The patient complains of shortness of breath and chest pain that began one hour ago. The patient also complains of left calf pain.
O: The patient is hypertensive, tachycardic, is breathing rapidly, and is sweating profusely. Breath sounds are diminished in the right lower lobe. The pulses in the left lower extremity are diminished, the left calf warm, swollen, and tender.
A: The patient appears to be suffering from a pulmonary embolism secondary to a deep vein thrombosis in the left lower extremity (Mayo Clinic, 2014). Blood and diagnostic tests are ordered as follows: complete blood count, complete metabolic panel, cardiac enzymes, d-dimer, PT/INR, PTT, ECG, ultrasound of left lower extremity, and CT of the chest with contrast. The results are listed below.
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Complete blood count is within normal limits. The metabolic panel is within normal limits. The cardiac enzymes are within normal limits, the most important being the troponin level which is less than 0.01, the d-dimer is elevated at 900 ng/ml (normal is <250 ng/mL) (Mayo Medical Laboratories, 2014). The ECG shows tachycardia, with no ST elevation, otherwise normal ECG. The ultrasound of the left lower extremity reveals a thrombus 4 cm long. The CT of the chest reveals an occlusion of the anterior basal segmental artery of the right lower lobe. The PT/INR and PTT results are within normal limits.
P: Anticipate admission of this patient to the ICU. The patient will need to be accurately weighed in anticipation of administration of a heparin drip to prevent further clots and dissolve the clot in the lung and the clot in the left lower extremity.
Pulmonary embolism is just one of many causes of chest pain. Although some causes are not medical emergencies it is important to seek medical attention. Early intervention and treatment, especially of cardiac related chest pain is essential in preventing continued or lasting damage to heart muscle.
Jarvis, C. (2012). Physical Examination and Health Assessment [VitalSouce bookshelf version]. Retrieved from http://digitalbookshelf.southuniversity.edu/books/978-1-4377-0151-7/outline/24
Mayo clinic. (2014). Pulmonary embolism. Retrieved November 4, 2014, from http://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/basics/definition/con-20022849
Mayo Medical Laboratories. (2014). D-Dimer. Retrieved November 4, 2014, from http://www.mayomedicallaboratories.com/test-catalog/Clinical and Interpretive/9290
National Institute of Health. (2011). Deep Vein Thrombosis: Symptoms, Diagnosis, Treatment and Latest NIH Research | NIH MedlinePlus the Magazine. Retrieved November 4, 2014, from http://www.nlm.nih.gov/medlineplus/magazine/issues/spring11/articles/spring11pg20-21.html
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