A 57-year-old male client is brought to the emergency department (ED) by emergency medical services (EMS) with reports of chest pain. The client was mowing his lawn and noticed chest pain described as tightness and pressure. The pain continued to increase over about 30 minutes, at which point the client decided to rest. The client’s wife called EMS when the pain was unrelieved after 20 minutes of rest. The client reports no previous episodes of this pain. His medical history includes hypertension, obesity, and a 20-year history of smoking, having quit about 5 years ago. He takes metoprolol succinate ER 25 mg PO daily.
1230:
The client presents to the emergency department (ED) after arrival via EMS with reports of increasing chest pain.
Assessment
Neurological:
Alert and oriented to person, place, time, and situation. Agitated. Denies headaches.
Cardiovascular:
Reported chest pain described as pressure and tightness, unrelieved with rest. Rapid, regular rhythm. Normal heart tones. Radial and pedal pulses 2+. Capillary refill 2 seconds.
Respiratory:
Rapid, shallow breaths. Clear breath sounds throughout bilateral lungs.
Gastrointestinal:
Within normal limits (WNL).
Genitourinary:
WNL.
Musculoskeletal:
WNL.
Pain:
Reports 7/10 tightness and pressure in the chest.
Started approximately 2 hours ago and progressively worsened, unrelieved by rest.
1600:
The client is admitted to the unit for observation.
Assessment
Neurological:
Alert and oriented to person, place, time, and situation.
Denies headaches.
Reports anxiety and tiredness related to admission.
Cardiovascular:
Reported chest pain described as squeezing that improved with nitroglycerin given in ED.
Tachycardia.
Normal heart tones.
Radial and pedal pulses 2+.
Capillary refill 2 seconds.
Respiratory:
WNL.
Gastrointestinal:
WNL.
Genitourinary:
WNL.
Musculoskeletal:
WNL.
Pain: Reported 2 on a 0 to 10 scale, a squeezing pain in chest that improved with nitroglycerin given in ED
1230:
Temperature: 98.1°F (36.7°C) orally
Heart rate: 121 beats/minute
Respirations: 21 breaths/minute
Blood pressure: 162/98 mm Hg
Oxygen saturation: 92% on room air
Body mass index (BMI): 32 kg/m² (normal 18–24.9 kg/m²)
Pain: 7/10 tightness and pressure in chest
1400:
Temperature: 98.4°F (36.9°C) orally
Heart rate: 124 beats/minute
Respirations: 22 breaths/minute
Blood pressure: 169/96 mm Hg
Oxygen saturation: 89% on room air
Pain: 8 on a 0 to 10 scale, tightness and pressure in chest
1430:
Temperature: 98.4°F (36.9°C) orally
Heart rate: 112 beats/minute
Respirations: 18 breaths/minute
Blood pressure: 151/84 mm Hg
Oxygen saturation: 96% via 2 L/minute nasal cannula
Pain: 2 on a 0 to 10 scale, squeezing in chest
1600:
Temperature: 98.2°F (36.8°C) orally
Heart rate: 106 beats/minute
Respirations: 17 breaths/minute
Blood pressure: 150/81 mm Hg
Oxygen saturation: 95% via 2 L/minute nasal cannula
Pain: 2 on a 0 to 10 scale, squeezing in chest
1245:
12-lead electrocardiogram (ECG)
Prothrombin time (PT), International normalized ratio (INR), troponin T, troponin I, C-reactive protein, cholesterol, triglycerides, high-density lipoproteins (HDL), low-density lipoproteins (LDL)
Titrate oxygen via nasal cannula to maintain oxygen saturation >94%
Insert peripheral IV (PIV) access and maintain per unit protocol
1400:
Aspirin 325 mg PO daily
Nitroglycerin 0.3 mg sublingual (SL) every 5 minutes up to 3 times PRN for chest pain
Titrate oxygen via nasal cannula to maintain oxygen saturation greater than 94%
1500:
Admit to observation unit.
| Test | Result | Reference Range |
|---|
| Prothrombin time | 12 sec | 11–12.5 sec |
| INR | 1.0 | 0.8–1.1 |
| Troponin T | 0.01 ng/mL | <0.1 ng/mL |
| Troponin I | 0.02 ng/mL | <0.03 ng/mL |
| C-reactive protein | 2.2 mg/dL | <1.0 mg/dL |
| Cholesterol | 240 mg/dL | <200 mg/dL |
| Triglycerides | 186 mg/dL | 40–160 mg/dL |
| HDL | 27 mg/dL | >45 mg/dL |
| LDL | 150.8 mg/dL | <130 mg/dL |
1300:
12-lead ECG: Sinus tachycardia with a 1st-degree heart block (PR interval 0.22 seconds) and ST depression.