Our patient is a 48-year-old man with a chief complaint of chest pain of 45 minutes duration.
Paramedics were called by dialing 911 and arrived on the scene within five minutes. They obtained the following pertinent history. While playing racquetball, the patient developed nausea and epigastric discomfort. He vomited without relief several times. The discomfort increased and became an intense substernal ache with radiation into the neck. It was unaffected by movement, body position, or breathing.
The patient denied any additional pertinent medical history. He specifically responded to the paramedics’ questions that he had no history of bleeding, stroke, hypertension, recent trauma or surgery.
In this urgent situation, a focused cardiovascular examination was also performed by the paramedics. The patient was anxious and mildly diaphoretic, his blood pressure was 90/60 mmHg in both arms, pulse rate fifty and regular, and respirations sixteen. His arterial pulses were normal and there was no jugular venous distention. On auscultation of the heart and lungs, they found no abnormalities.
Based on the patient’s focused history and physical examination, immediate management was undertaken by the paramedics. They placed the patient on an ECG monitor and also obtained a 12-lead electrocardiogram. Nasal oxygen, insertion of a peripheral IV line, and appropriate drug therapy were also initiated. The patient was quickly transported to a nearby emergency department, where monitoring and oxygen therapy were continued and appropriate studies were ordered, including another electrocardiogram and cardiac markers.
As the patient was being evaluated, further history was obtained in the emergency department from his wife. She stated that he had been healthy and active and had had no medical problems or medical care in many years. She was worried because he smoked a package of cigarettes per day for at least twenty years, and his father died of a heart attack at age fifty-two. There was no history of drug use.