Saturday, 25 December 2010

58 year old male CC: Chest pain

Here's an interesting case sent in by a faithful reader who wishes to remain anonymous.

EMS is called to the residence of a 58 year old male complaining of chest discomfort.

On arrival the patient is found sitting on the edge of the bed. He is anxious but alert and oriented to person, place, time, and event.

He was awakened from sleep by chest discomfort.

Onset: 30 minutes ago while sleeping
Provoke: Nothing makes the pain feel better or worse
Quality: Severe pressure or "ache"
Radiate: The pain does not radiate
Severity: 10/10
Time: He has had chest pain before but "not this bad"

Past medical history: HTN, dyslipidemia

Medications: Lipitor, Norvasc, ASA

Vital signs are assessed.

RR: 24
Pulse: 136
NIBP: 160/98
SpO2: 94 on RA

Breath sounds: basilar rales

The patient admits to mild dyspnea. He states that he has "gained a little weight" recently and his doctor was getting ready to put him "on a water pill."

Temp: 99.1
BGL: 138

The cardiac monitor is attached.

A 12-lead ECG is captured.

The patient is given 324 mg of aspirin, 0.4 mg NTG SL spray and placed on CPAP.

Another 12-lead ECG is captured.

The patient is loaded for transport and another rhythm strip is captured.

What do think is going on with this patient's heart rhythm?

What do you think is wrong with this patient?

You are 15 minutes away from the local non-PCI hospital and 60 minutes away from a STEMI receiving center.

Where would you transport this patient and why?