Posted: September 8th, 2023

Differential Diagnosis and Treatment Plan for Acute Chest Pain

Discussion Content
Question 15 PointsFor the Cardiovascular topic, please read the following clinical case scenario:
____
SUBJECTIVE:
Samuel, a 48 – year – old male, presents to the office with mild – to – moderate chest pressure with radiation to his back. Samuel reports that he was awakened from sleep at 7:00 a.m. with chest pressure, initially described as soreness across his anterior chest and through to his back. He rates his pain + 6/10. He felt as though, if he could just belch, he would feel better. His wife drove him to the office to be here when it opened at 9:00 a.m. She tried to convince Samuel to go to the emergency room; but he emphatically refused, insisting on going to the office first. Upon arrival at the office, you take Samuel back to an examination room and instruct the receptionist to call 911.

Past medical/surgical history: Diabetes mellitus type 2.

Family history: He has a family history of premature coronary artery disease. His father died of acute myocardial infarction ( AMI ) at age 45. One brother died of AMI at age 49. Social history: He has smoked for 25 years but has reduced his smoking to 1 pack per day since his brother’s death two years ago. He has put on 25 pounds in the past two years and is generally sedentary.

Medications: Samuel was diagnosed with type 2 diabetes last year. He has been fairly well controlled with diet and Metformin, 500 mg daily. His last hemoglobin A1C was 7.4 two months ago.

Allergies: Latex.

OBJECTIVE
General: He is anxious and showing signs of chest pain as you enter the office room. He is slightly diaphoretic. He took an oral aspirin on the way to the office.
Vital s signs: BP: 192/96; P: 102; R: 22; T: 97.8. His SpO2 is 90%.
ECG: His stat ECG shows ST segment depression and T wave inversion in leads II and III.
Cardiovascular: His heart tones are muffled with an S3 gallop. His hands and feet are cool to touch. Radial pulses are 2 +. Pedal and posterior tibial pulses are 1 +. He has neck vein distention of 5 cm with the head of the bed at 90 degrees. He has no carotid bruits, heaves, or thrusts. His PMI is at the 5th ICS, left mid-clavicular line.

Respiratory: He has harsh rhonchi in the upper lobes bilaterally and a nonproductive cough.
__________

Based on the described case scenario, please answer two of the following questions using at least one paragraph answering each question.
-Which diagnostic or imaging studies should be considered to Help with or confirm the diagnosis?
-What is the most likely differential diagnosis and why?
-What is your plan of treatment?
-Are any referrals needed?
-Does the patient’s family history impact how you treat this patient?
-What are the primary health education issues?
-Are there any standardized guidelines you should use to assess/treat this case?
DQ Submission requirements:
The submitted paper should be according to current APA7 guidelines.
Must utilize credible data sources such as CINAHL, MEDLINE, Embase, Clinical Key, and Cochrane Library (Accessed from the library page at the fnu.edu website).
FNU Librarians are available to Help each student with retrieving the required scholarly content.
2 or more scholarly sources must be utilized.
All sources must have been published within the last five years.
All article sources must be cited.
Two responses to your classmates by sunday 11.59PM

Differential Diagnosis and Treatment Plan for Acute Chest Pain
Samuel, a 48-year old male with a family history of premature coronary artery disease, presents with chest pressure radiating to his back. His symptoms, vital signs including elevated blood pressure and heart rate, ECG findings of ST segment depression and T wave inversion, and physical exam findings of muffled heart tones and distended neck veins are concerning for an acute coronary syndrome such as a myocardial infarction (MI) (Mayo Clinic, 2022a).
The most likely differential diagnosis given Samuel’s presentation is an ST-elevation myocardial infarction (STEMI) (Mayo Clinic, 2022b). STEMIs occur when a coronary artery becomes completely blocked, preventing blood flow to the heart muscle and causing damage. Key factors supporting STEMI include Samuel’s chest pain described as pressure, radiation to the back, onset at rest, timing of symptoms on awakening, elevated troponin levels, and diagnostic ECG changes of ST segment elevation or depression.
Other potential differentials include non-ST elevation MI (NSTEMI), unstable angina, pericarditis, pulmonary embolism, and aortic dissection. However, NSTEMI and unstable angina are less likely given the severity of Samuel’s symptoms and ECG changes. Pericarditis, pulmonary embolism, and aortic dissection do not fully explain Samuel’s risk factors, family history, symptoms, and exam/diagnostic findings.
The treatment plan for Samuel begins with activating emergency medical services for transport to the hospital. Per American Heart Association guidelines, aspirin should be chewed and swallowed to help prevent clot formation (Amsterdam et al., 2014). Oxygen via nasal cannula at 2-4 L/min should be administered to maintain an oxygen saturation above 90% (O’Gara et al., 2013). Intravenous access should be obtained, and nitroglycerin given sublingually every 5 minutes for chest pain while monitoring vital signs and ECG for hypotension (Amsterdam et al., 2014).
In the emergency department, diagnostic studies are crucial. A repeat ECG every 10-15 minutes can detect changes and guide management (O’Gara et al., 2013). Emergent cardiac catheterization is indicated given the high-risk features of Samuel’s presentation. This angiogram will identify any obstructive coronary lesions causing the MI. If an occlusion is found, percutaneous coronary intervention (PCI) to open the blocked vessel with balloon angioplasty and stent placement is the primary reperfusion strategy (Amsterdam et al., 2014).
Samuel will likely require intensive care unit admission after the cardiac catheterization for monitoring, further anti-ischemic medications, and treatment of any complications. Secondary prevention with dual antiplatelet therapy, high-intensity statins, beta-blockers, and ACE inhibitors should be initiated (Amsterdam et al., 2014). Referral to cardiac rehabilitation is recommended upon discharge to address modifiable risk factors through diet, exercise, smoking cessation counseling, and medication adherence education (Balady et al., 2011).
In summary, Samuel presents with STEMI requiring emergency reperfusion therapy. Timely diagnosis and treatment can help limit myocardial damage from the ongoing ischemia. Ongoing risk factor modification and secondary prevention strategies aim to prevent recurrent events.
References:
Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., … & Jaffe, A. S. (2014). 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64(24), e139-e228.
Balady, G. J., Ades, P. A., Bittner, V. A., Franklin, B. A., Gordon, N. F., Thomas, R. J., … & American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, Council on Clinical Cardiology; American Heart Association Council on Nutrition, Physical Activity, and Metabolism. (2011). Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation, 124(25), 2951-2960.
Mayo Clinic. (2022a, March 11). Myocardial infarction (heart attack). Retrieved November 1, 2022, from https://www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106
Mayo Clinic. (2022b, March 11). ST-elevation myocardial infarction (STEMI). Retrieved November 1, 2022, from https://www.mayoclinic.org/diseases-conditions/heart-attack/in-depth/stemi/art-20046760
O’Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Chung, M. K., de Lemos, J. A., … & Granger, C. B. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61(4), e78-e140.

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