Discussion Question

There are many differential diagnoses for chest pain

• Acute myocardial infarction
• Aortic dissection; pericarditits
• Acute coronary artery insufficiency
• Pulmonary embolism
• Pneumothorax
• Pneumo mediastinum
• Pneumonia
• Esophageal spasm
• Esophagitis
• Biliary colic
• Acute pancreatitis
• Peptic ulcer disease

-Choose one of the above differential diagnoses and discuss the presenting/associated symptoms, diagnostic tests, and a treatment plan. Support whether or not you would refer the patient to another health care provider for treatment.

-Use APA 6th format. Include in text citations and 2 peer review journals.

Part B Respond to classmates and provide substantive comments no more than 100 words. Yes respectful and include intext citations and references

Stephen’s Response

There are a long list of causes for chest pain. Perhaps the one that comes to mind first for the general public is acute myocardial infarction (AMI). In addition to chest pain, the patient may present with pain in the right arm, both arms, neck, shoulders, back, or jaw (Bruyninckx & Aertgeerts, 2008). The pain may be accompanied by difficulty breathing, shortness of breath, sweating, nausea, vomiting, heartburn, anxiety, dizziness, or a rapid heart beat (Cleveland Clinic, 2017b). When dealing with chest pain, many diagnostic tests are performed in order to rule out other causes, these include chest xray, some labs like a D dimer or WBC, chest ct, etc. Diagnostic tests used to confirm a diagnosis of acute MI include labs including tropononin and CK, a 12 lead EKG, an echocardiogram, and a diagnostic catheterization to show blockages. Once a diagnosis of AMI is confirmed with diagnostic testing, the treatment plan should include medications and interventions. Medications used in ami include aspirin, heparin, antifibrolynics, antiplatelets, and pain medication (Cleveland Clinic, 2017a. The goal of many of these medications are to prevent further development of the clot within the coronary vessels. Interventional procedures are aimed at clot removal and reperfusion of the cardiac tissue. These interventions usually involve cardiac catheterizations with balloons and stent placements. More severe cases require cardiac bypass surgery (Cleveland Clinic, 2017a). Any patient who presents in the primary care setting complaining of chest pain with high suspicion of cardiac ivvolvement needs to be sent to the emergency department for evaluation and potential intervention

References

Bruyninckx, R., Aertgeerts, B., Bruyninckx, P., & Buntinx, F. (2008). Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome a diagnostic meta-analysis. The British Journal of General Practice, 58(547), e1–e8. http//doi.org/10.3399/bjgp08X277014.

Cleveland Clinic. (2017a, June 1). Heart attack diagnosis and treatment. Retrieved from https//my.clevelandclinic.org/health/diseases/168…

Cleveland Clinic. (2017b, June 1). Heart attack symptoms. Retrieved from https//my.clevelandclinic.org/health/diseases/168…

April’s Response

ST Elevation Myocardial Infarction (STEMI)

Acute myocardial infarction (MI), one of the many causes of chest pain, occurs approximately 1.5 million times a year in the U. S. MI, known in layman’s terms as a “heart attack,” accounts for approximately 500,000 deaths annually, with over half of individuals dying before they reach the hospital (Warnica, 2016). MI is defined as evidence of myocardial injury or necrosis in a clinical setting that is consistent with myocardial ischemia. MIs can be classified as one of two types, ST elevation MI (STEMI) or non-ST elevation MI, depending on EKG pattern (Reeder & Kennedy, 2018).

Symptoms of STEMI

Chest pain, often described as a deep substernal tightness, aching, or pressure, is the most common presenting symptom of a STEMI. The pain may radiate to the back between the shoulder blades, left arm, left jaw, or bilateral shoulders. Additionally, patients may also experience diaphoresis, shortness of breath, nausea, vomiting, anxiety, and generalized weakness. Other patients may present with syncope, peripheral or central cyanosis, thready pulse, variable blood pressure, and even sudden cardiac arrest depending on what area of the heart is affected. It is important to note that atypical presentations are also possible and are most common in women, patients with diabetes, and the elderly. In fact, approximately 20% of MIs are considered “silent,” as they are asymptomatic or cause only mild, vague symptoms. Two-thirds of patients also report not feeling well for days to weeks before their MI, often experiencing a period of prodromal symptoms including fatigue, nonspecific dyspnea, and intermittent chest pain or “heartburn” (Reeder & Kennedy, 2018; Warnica, 2016).

Diagnostic Tests

An electrocardiogram (EKG) is the most important diagnostic test when a patient presents with chest pain presumed to be cardiac in nature. Ideally, an EKG should be obtained within 10 minutes of patient presentation (Warnica, 2016). In cases of STEMI, the EKG is generally diagnostic and will show ST-segment elevation in 2 or more contiguous leads. The elevated leads coincide with the involved region of the myocardium, localizing the MI and often predicting the related artery. Cardiac markers are cardiac enzymes and cell contents that are released into the bloodstream when myocardial cells are damaged. Troponin, the most sensitive and specific marker for myocardial injury, should be drawn on patients presenting with chest pain. A troponin is considered “positive” when it is resulted as >99^th percentile above the upper reference limit (Reeder & Kennedy, 2018).

Treatment Plan

The initial therapy for a patient experiencing a STEMI is to reduce ischemic pain, stabilize hemodynamic status, and reduce ischemia while assessing what method of reperfusion to utilize. Aspirin, nitrates, and morphine are often used during the initial treatment of such patients. Ultimately, reperfusion is the main goal of STEMI treatment, as timely restoration of blood flow to the myocardium is necessary to salvage heart muscle and reduce mortality. Reperfusion can be achieved either through fibrinolytic medications or by direct percutaneous coronary intervention (PCI). When PCI is not readily available, fibrinolytic therapy should be administered within 30 minutes of patient arrival at the hospital (Reeder & Kennedy, 2018). Examples of fibrinolytics include TNKase, alteplase, reteplase, and streptokinase (Warnica, 2016). Patients should then be transferred rapidly to a facility capable of PCI, which requires a cardiac catheterization lab and stenting to open the coronary artery and restore blood flow (National Heart, Lung, and Blood Institute, 2018).

Referral and Transfer

An acute STEMI is a medical emergency and should be treated as such (Reeder & Kennedy, 2018). If I were working in the clinic and encountered a patient experiencing a STEMI, I would have the patient sent to the closest emergency department (ED) via ambulance. In the rural hospital where I currently work as an ED RN, the closest PCI center is over 250 miles away. In such cases, we give TNKase and transfer them via air ambulance to closest facility with cardiac cath lab services.

References

National Heart, Lung, and Blood Institute. (2018). Percutaneous Coronary Intervention. Retrieved from https//www.nhlbi.nih.gov/health-topics/percutaneous-coronary-intervention

Reeder, G. S. & Kennedy, H. L. (2018, September 24). Diagnosis of acute myocardial infarction. Retrieved from https//www.uptodate.com/contents/diagnosis-of-acute-myocardial-infarction#H8

Warnica, J. W. (2016). Acute Myocardial Infarction. Retrieved from https//www.merckmanuals.com/professional/cardiovascular-disorders/coronary-artery-disease/acute-myocardial-infarction-mi