Chest Discomfort/Tightness & Pacers Case

[1EMT-P]

You respond to a 58 year old white female patient complaining of intermittent right sided chest discomfort/tightness that goes away with rest. The patient reports that she has not been feeling well for the past two weeks & that her Dr. had ordered a BMP, CBC, CK, CK-MB, ESR, LFT's, Lipids, 12 Lead Ecg & Chest X-ray. The patient reported that her ALT, AST, Cholesterol, H&H & ESR were slightly elevated and that her CXR was normal & that her Ekg came back abnormal.

Allergies: IV Contrast, Motrin & Sulfa.

Medications: Albuterol MDI, ASA 81mg, Ativan 4mg, Lasix 40mg, Lexapro 20mg, Lopressor 100mg, Protonix 40mg, Wellbutrin 300mg, Co Q10 120mg & Vitamin E 400IU.

PMHX: Allergies, Anxiety, Asthma, Brady-Tachy Syndrome ( Dual Chamber Demand Pacer), Chest Discomfort/Tightness, Depression, HTN & SAH.

GCS = 15

Head - Intact

Ears - Intact

Eyes - PEAR

Nose - Intact

Throat - - Edema or JVD, Midline

Chest - Decreased Breath Sounds/+ Wheezes/ Intermittent Right Sided Chest Discomfort ( Non burning & Non radiating )

Abdomen - Soft/Non-tender - N/v

Extremities - + CMS, + Edema

Vitals: BP 118/84, Ekg Abnormal Paced Rythmn of 89, Resp. 24. Sp02 96% on Room Air.

Treatment: Oxygen & 4 81mg Chewable ASA. The pt refused both Nitro & IV therapy.

Is there anything else that could have been done for this patient? Any ideas what might be wrong with this patient?

[becksdad]

I was going to ask all kinds of questions for more information, but instead of doing that, can you fill us in? There's at least 10 more questions I would have asked, depending on where HPI led me....

[fiznat]

12 lead EKG!!! What do you mean the previous EKG came back abnormal? What about it was abnormal? What did your 12 lead show? This information is pretty critical.

I would have pressed the issue on the IV. Most people refuse IVs right away, but can be convinced. This patient needs one.

Wheezes might have bought her a breathing treatment depending on the rest of her presentation.

Peripheal edema, not a lot of fluid in the lungs and right sided chest pain all makes me worry about RVI. A 12 lead is necessary of course, but I most likely wouldnt be giving NTG to this patient anyways.

What do you mean the paced rhythm was abnormal? Abnormal because it is paced or a paced rhythm that was also abnormal in some way?

Also its interesting she has an allergy to sulfa drugs and yet she takes Lasix, which is a sulfa drug.

[1EMT-P]

The patient's 12 Lead Ecg showed a paced rhythm, which the monitor interpreted as abnormal. Her rhythm did not appear abnormal to me it appeared to be a sinus rhythm with pacing. The patient had a long history of brady-tachy syndrome & new that she could refuse the IV, so we did not push the issue we explained the risks & had the patient sign off that she was refusing.

The patient's Primary Care Dr. told her that he thought she was having A-Fib & wanted to put her on Coumadin, but her Cardiologist checked her pacer & told her that she was not having A-Fib, he told me that a 12 Lead Ecg is pretty much useless in patients with pacers because they usually come back as abnormal. The patient was placed on 324mg of aspirin every day & scheduled for an Echo & Stress Test.

[ERDoc]

The patient's 12 Lead Ecg showed a paced rhythm, which the monitor interpreted as abnormal. Her rhythm did not appear abnormal to me it appeared to be a sinus rhythm with pacing. The patient had a long history of brady-tachy syndrome & new that she could refuse the IV, so we did not push the issue we explained the risks & had the patient sign off that she was refusing.

The patient's Primary Care Dr. told her that he thought she was having A-Fib & wanted to put her on Coumadin, but her Cardiologist checked her pacer & told her that she was not having A-Fib, he told me that a 12 Lead Ecg is pretty much useless in patients with pacers because they usually come back as abnormal. The patient was placed on 324mg of aspirin every day & scheduled for an Echo & Stress Test.

First off, -5 for depending on a machine to do your assessment (tips hat to Dust). Most machines have terrible ability to interpret anything that is not NSR. They are good for assessing your intervals, assuming that your rate is not too high or the voltage is not too low. NEVER depend on the machines results.

A paced rhythm is pretty useless at looking for much. You should be able to see AFib however. In most cases it is going to look like a ventricular rhythm/BBB. Although, this depends on what kind of pacer they have.

[1EMT-P]

First off I did not depend on a machine to do my assessment... I did a complete assessment & connected the patient to the monitor to see her rate & rhythm... The machine in question was made by Medtronic as was the patient's pacer, so it should have been able to safely analyize the patient's rhythm.

[ERDoc]

First off I did not depend on a machine to do my assessment... I did a complete assessment & connected the patient to the monitor to see her rate & rhythm... The machine in question was made by Medtronic as was the patient's pacer, so it should have been able to safely analyize the patient's rhythm.

Doesn't matter who made the machine, they suck at reading EKGs. Irrelevant who made the pacer.

[becksdad]

I've been watching this thread, and so far I haven't seen the questions I would want to ask. Patient hasn't been feeling well for 2 weeks? What is the Hx of that? Had URI? Cough? Fever? SOB different in nature from her typical asthma? Re decreased breath sounds uni-or bilateral? Did you have a good stethoscope? Reason I ask, our agency provides cheap sprague stethoscopes that suck for all but the most pronounced changes. Could there have been friction rubs?

Is there anything else that provokes or palliates pain besides rest? Such as deep inspiration? The elevated resp. rate could be in response to pain on inspiration.....Relief with her Albuterol?

Some lab results referrable to liver elevated. Any Hx of cholecystitis? Recent worsening of GI complaints? (she takes Protonix). I know a few of these questions may be a bit of a stretch, but I find that thorough history taking can often focus the search. The answers to questions usually lead to more specific questions that you wouldn't have considered before you get a more complete picture.

I am not discounting the possibility of cardiac causes of the patients discomfort. Lord knows plenty of people present atypically (especially women). But I also think we often get tunnel vision, and focus solely on cardiac when someone complains of "chest discomfort". That is actually a pretty generic complaint that I think needs to be more specifically defined. It is even more tempting to focus on cardiology when a patient has a Hx of cardiac problems.

So while remaining alert to anything specifically cardiac, I would be searching for answers to R/O or confirm suspicions of differential diagnoses. Did you follow-up and get any further info on this patient, 1EMT-P? I would be curious to find out what went on.

[1EMT-P]

The patient has not had any more episodes of chest pain/tightness since having her pacer adjusted.

[Just Plain Ruff]

when did she have her pacer adjusted. You stated in your opening line that you were called for intermittent chest pain.

Did you say she had any type of fever? If a fever is present I would begin to suspect pneumonia or bronchitis. This is why I suspect pneumonia or bronchitis from your post "Chest - Decreased Breath Sounds/+ Wheezes/ Intermittent Right Sided Chest Discomfort ( Non burning & Non radiating )"