EMT Notes
Patient appears to be anxious and hyperventilating. Encouraged patient to slow breathing down. VS obtained: Pulse 120; BP 152/112; Resp. 22, shallow. Patient complains of: intermittent sharp chest pain located in sternum area non-radiating; started at 0230. Pain is 8 on a scale of 1-10. Patient also complains of an increase in pain upon palpation to the sternum and with coughing. Patient has a productive cough of a clear, thick substance. Denies fever or recent trauma. Patient states she has had the chills for the past week. Lung sounds are clear and present in all lobes excluding the left lower lobe, which is diminished. Abdomen soft non-tender. Further exam unremarkable.
EMT Impression
Nursing Triage Note
The triage is timed 0321. The triage nurse noted: chest pain, productive cough. Started 1 week ago, has just worsened. Has chills and cough. PMH: HTN and CVA. EMS Meds 4 ASA, 3 NTG. Meds include: amlodipine, atenolol, nortriptyline, desloratadine, escitalopram, tizanidine, sumatriptan, hydrocodone.
Triage Vitals (timed 0230): Pulse 97, BP 142/115, Resp 14, Temp 97.2°F (36.2°C), SpO2 98%, Pain 8/10.
The physician saw the patient at 0348; he documented his exam on an electronic medical record using a chest pain template.
History of Present Illness
Chief Compliant | Chest Pain |
Started | Awakened her 0250 |
Time Course | Still present; constant |
Quality | Pressure, tightness, sharp |
Location of Pain | The sternal area is circled on the body illustration. |
Radiation | This section was not filled in; radiation was not addressed. |
Associated Symptoms | Nausea, shortness of breath and sweating; no vomiting |
Worsened by | Deep breath |
Relieved by | Nitroglycerin x 3 by paramedics and MS gave partial relief; oxygen |
Onset During | Sleep |
Pain Severity | Severe |
Pain When Seen in ED | The physician noted "recurring," without a number. |
Similar Symptoms Previously | 2 episodes, brief, this past week |
ROS
Positive for occasional cough, headache. Negative for fever, ankle swelling, leg pain, blackouts, abdominal pain, black stools, problems urinating, skin rash, joint pain. All systems neg. except as marked or checked.
PMH
High blood pressure, gestational diabetes, chronic bronchitis, CVA three years ago, migraines. PMH negative for high cholesterol, heart disease, DVT risk factors, peptic ulcer and gallstones.
Allergies: No known allergies
Social History: Negative
Family History: Negative for CAD. Positive for lung cancer, epilepsy and diabetes.
Physical Exam:
General | Appears anxious. She is holding her chest. |
HEENT | Checked as normal on the template |
Neck | Checked as normal on the template |
Respiratory | Checked as normal on the template |
CV | Regular rate and rhythm, no murmur, no gallop, no rub |
Chest | Mild chest wall tenderness, left side, mid clavicular line |
Abdomen | Checked as normal on the template |
The skin, extremities, neurologic and mental status exam were also documented as normal.
The ECG, which the physician interpreted as normal, is shown below:
ED Course
The physician ordered the ED acute chest pain protocol, which included:
The initial chest X-ray was interpreted as normal by the emergency physician, who noted, "no infiltrates, normal heart size." Her Pulse Ox was 98%-99% on room air. Her electrolytes, CBC, and BMP were all within normal limits; troponin was 0.05 (reported as normal for this hospital).
Nursing Progress Notes
0425 | Morphine 2 mg IVP. Pain 8/10. Vitals: Pulse 84, BP 142/92, Resp 20. |
0435 | Toradol 60 mg IM. |
0545 | The patient was discharged home. |
Patient Discharge
Physician Impression | Left-sided chest wall pain, musculoskeletal |
Discharge Instructions | Warm pack to chest wall |
Prescription | Naproxen and acetaminophen/hydrocodone |
Follow-Up | None |
Discharge Vital Signs | Pulse 76, BP 107/69, Resp 14, Pain 6/10 |
Outcome
Eleven days later, the patient presented to the same ED in full cardiac arrest. Autopsy revealed a 95% atherosclerotic narrowing of the LAD.
Following the depositions with the physician and nurses, the defendants settled out of court with the patient’s family for an undisclosed amount.
Case Discussion
Ischemic heart disease is underdiagnosed in women. Look at the list of typical signs/symptoms; there is no way to rule out acute ischemic heart disease based on these elements of the history and physical and a single troponin and ECG.
Atypical | Typical |
Anxious | Chest pain |
Hyperventilating | Risk factor - HTN |
Non-radiating pain | Pain feels pressure-like and tight (MD) |
Sharp pain | Nausea and vomiting |
Pain on chest palpation | Diabetes |
Pain with coughing | Nausea and vomiting |
Pain with deep breath | |
Productive cough | |
Chills for the last week | |
No improvement with NTG | |
Onset during sleep | |
Headache | |
Appears anxious | |
Chest wall tenderness |
What happened in this case?
When you look at cases like this in retrospect, it is easy to wonder how a board certified emergency physician could possibly have discharged this patient with a diagnosis of chest wall pain. Don’t discount the power of heuristics or the cognitive disposition to respond – in other words, human bias. The patient was 35-years-old, complained of a productive cough, and had worsening pain with cough and pain with palpation of the chest wall. She described the pain as sharp and she had reported intermittent chills; she had a normal ECG and initial troponin.
This case is presented in this issue in order to help practitioners avoid bias and recognize the pitfalls leading to this common failure to diagnose.
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