Case No.
2:
A 58-year-old male presents with a complaint of severe chest pain over the last hour. He states
that he did not call 911 because he cannot afford an ambulance.
INTRODUCTION
Acute Coronary Syndrome (ACS) refers to a spectrum of conditions compatible with
acute myocardial ischemia and/or infarction due to an abrupt reduction in coronary blood flow
(Centers for Disease Control and prevention [CDC], 2021). Management for ACS focuses on
stabilizing the patient’s condition, relieving ischemic pain, and providing antithrombotic therapy
to reduce myocardial damage and prevent further ischemia (American Heart Association [AHA],
2015).
The American College of Cardiology (ACC) in conjunction with AHA and the European
Society of Cardiology (ESC) has published new recommendations for the diagnosis and therapy
of non-ST-elevation (NSTE) acute coronary syndrome. The updates emphasize the importance of
high-sensitivity cardiac troponin testing (hs-TnI) for diagnosis, include coronary computed
tomography (CT) imaging to rule out lower-risk patients, and emphasize the importance of
personalized antiplatelet regimens, systems of care, and quality improvement (Coven, 2020).
PATIENT’S GENERAL INFORMATION
The healthcare provider must perform a full history evaluation of the patient to identify
factors supporting acute coronary syndrome as the main diagnosis. To obtain the patient’s health
history, subsequent interview questions can help.
Age: 58 years old
Gender: Male
Chief Complaint:
The patient complains of severe chest pain over the last hour.
Present Health History:
Provocative: What brings the pain on? Rest, emotional upset, after eating, or during
sexual intercourse? What makes it better? What makes it worse?
Quality: Describe the pain? What does it feel like (stabbing, burning, tightening,
sharp etc.)?
Region/Radiation: Where is the pain? Does it spread anywhere else?
Severity: How severe is the pain? On a scale from 1-10 how bad would you rate
your chest pain?
Time: When did the chest pain start? What were you doing when the chest pain
started? How long have you had the chest pain? How long does the pain
last? Does the pain go away?
Past Health History:
Childhood Illnesses: Did you have any childhood illnesses?
Chronic Illnesses: Did you have hypertension, diabetes, or any cardiovascular diseases?
Hospitalizations: Have you been hospitalized in the past? Did you have any surgeries? Have
you had accidents or injuries?
Medications: Did you have any maintenance medications?
Family History:
Hereditary Illnesses: Did you have family history of hypertension, diabetes, cancer or any
cardiovascular illnesses?
Social History:
Smoking: Do you smoke tobacco? How many packs per day?
Alcoholic Beverage: Do you drink alcoholic beverages? How much and how often?
SOAP NOTE
Subjective Data
Review of Systems (14 Systems recognized by the Centers for Medicare and Medicaid Services):
Constitutional Symptoms:
The patient denies headache, fatigue, loss of appetite, night sweats, and malaise.
Eyes:
The patient denies blurring of vision or any eye discomfort.
Ears, Nose, Mouth, Throat:
The patient states that she has no any ear problems such as hearing loss, tinnitus, and ear
pain. She also denies any conditions involving the nose such as loss or diminished sense of
smell, nasal congestion, and nosebleeds. She has no pain and difficulty swallowing as well.
Cardiovascular:
The patient reports severe chest pain over the last hour.
Respiratory:
The patient reports shortness of breath.
Gastrointestinal:
The patient states that she has good appetite and does not experience problem with bowel
elimination.
Genitourinary:
The patient denies urinary urgency, nocturia, hematuria, and burning urination.
Musculoskeletal:
The patient denies any muscle pain or stiffness, joint pain, and back pain.
Integumentary:
The patient denies skin irritation and pruritus.
Neurological:
The patient denies having memory loss, tremors or seizures and sensorimotor deficits.
Psychiatric:
The patient reports anxiety due to condition.
Endocrine:
The patient denies polydipsia, polyuria, and intolerance to heat and cold.
Hematologic/Lymphatic:
The patient denies history of bleeding or surgeries involving the lymphatic system such
as tonsillectomy and splenectomy.
Allergic/Immunologic:
The patient denies having allergies to food and drugs.
Objective Data
Review of Systems (14 Systems recognized by the Centers for Medicare and Medicaid Services):
Constitutional Symptoms:
The patient’s vital signs are as follows: Temp= 98.6°C, PR= 110 bpm (increased heart
rate secondary to a high sympathoadrenal discharge), RR= 24 bpm (increased respiratory rate in
response to pulmonary congestion or anxiety), BP= 130/90 mmHg (initially elevated blood
pressure because of peripheral arterial vasoconstriction resulting from an adrenergic response to
pain and ventricular dysfunction), SpO2= 98% on room air.
Eyes:
The patient has no eye redness, irritation, and scleral icterus. There’s no strabismus or
nystagmus. Both pupils are equal, round, and reactive to light and accommodation.
Ears, Nose, Mouth, Throat:
The patient has no palpable lumps or masses in the auricle of the ear, with patent ear
canal and pearly grey tympanic membrane. His nose is symmetrical with no discoloration or
swelling. Nasal mucosa is pinkish red with no discharges, bleeding, and swelling. The patient’s
lips are also symmetrical, pink, and smooth. The oral mucosa and gums are moist and pink with
normal dentition. The trachea is in the midline with non-palpable lymph nodes.
Cardiovascular:
The patient’s jugular vein is not distended. His heart rate upon examination is 110 beats
per minute with an irregular rhythm; S1-S2 present, not diminished or accentuated, no S3 or S4.
A systolic murmur was heard (maybe due to acute left ventricular dilatation). Peripheral pulses
were palpable and 3+ (full and bounding) with a normal capillary refill.
Respiratory:
Patient’s chest moves symmetrical with respiration and abnormal breath sounds pertinent
to congestion heard upon auscultation.
Gastrointestinal:
The patient has no palpable mass all over the 4 abdominal quadrants. Active bowel
sounds heard upon auscultation.
Genitourinary:
The patient’s urinary bladder is not palpable, no suprapubic tenderness.
Musculoskeletal:
The patient does not have atrophied muscles or joint dislocations. Full range of motion
seen in both upper and lower extremities.
Integumentary:
The patient has normal skin turgor with no tenting. His skin is pale and having cold
sweats.
Neurological:
Upon assessment, the patient was alert and oriented to person, place, and time. All cranial
nerves were grossly intact and her reflexes were normal with normal muscle tone.
Psychiatric:
The patient was feeling nervous or tense due to condition.
Endocrine:
The patient has no thyroid gland enlargement, exophthalmos, or baldness.
Hematologic/Lymphatic:
The patient has pink, symmetrical and normal-size tonsils. He has non-palpable lymph
nodes.
Allergic/Immunologic:
The patient has no visible skin rash, swelling, or pain relevant to allergic reactions.
Diagnostic Tests:
According to the American Heart Association (2015), a patient having signs and
symptoms of acute coronary syndrome must have their cardiac rhythm and biomarker checked.
ECG Electrocardiogram; a diagnostic test that detects cardiac abnormalities by
measuring the electrical activity generated by the heart as it contracts.
hs-TnI High-sensitive Troponin I; biomarker to expedite the evaluation of
patients with possible acute coronary syndrome.
Assessment
Primary Diagnosis: Acute Coronary Syndrome
Due to the high mortality and morbidity of coronary disease, in the event of chest pain, the
practitioner will always consider the possibility of an acute myocardial infarction or unstable
angina. Chest pain is a common complaint and encompasses a broad differential diagnosis that
includes several life-threatening causes. A workup must focus on ruling out serious pathology
before a provider considers more benign causes (Johnson & Ghassemzadeh, 2021).
Pertinent Positive: Severe chest pain
Pertinent Negative: Pain spreading from the chest to the shoulders, arms, upper
abdomen, back, neck, or jaw.
Differential Diagnosis No. 1: Acute Pericarditis
Acute pericarditis is a pericardial inflammation characterized by pericarditic chest discomfort,
pericardial friction rub, and serial electrocardiographic alterations. Pericarditis can have an
infectious or noninfectious etiology. Men are more likely than women to get acute pericarditis.
Palpitations may be the initial complaint, but chest discomfort is the most common pericarditis
symptom, commonly precordial or retrosternal with referral to the trapezius ridge, neck, left
shoulder, or arm. The pain is often pleuritic, although it can be acute, dull, aching, burning, or
pressing, and the severity can range from barely detectable to severe. The discomfort is worst
during inspiration, lying flat, swallowing, and movement, and it can be eased by tilting forward
when seated (Spangler, 2019).
Pertinent Positive: Severe chest pain
Pertinent Negative: Low-grade intermittent fever, dyspnea/tachypnea, cough, and
dysphagia (Spangler, 2019)
Differential Diagnosis No. 2: Gastroesophageal Reflux Disease (GERD)
When taking a deep breath or coughing, people with GERD may experience brief, severe chest
pain. Chest discomfort caused by reflux is less likely to feel like it's coming from deep within
your chest. It may feel as though it's closer to your skin's surface, and it's frequently
characterized as scorching or sharp (Roth ,2018).
Pertinent Positive: Severe chest pain
Pertinent Negative: Trouble swallowing, frequent burping or belching, a burning
sensation in the throat, chest, or stomach, and a sour taste in the
mouth caused by regurgitation of acid.
Plan
Treatment Plan:
Upon arrival to the Emergency Department, initiate an intravenous access (IV) line,
provide 162 mg to 325 mg chewable aspirin, clopidogrel, or ticagrelor (unless bypass surgery is
imminent), reduce discomfort, and consider oxygen treatment. Nitroglycerin has proven a
mortality benefit, aim for 10 percent mean arterial pressure (MAP) decrease in normotensive
individuals and 30 percent MAP reduction in hypertensive patients; avoid in hypotensive patients
and those with inferior ST elevation. Patient with ST elevation on ECG patients should get
urgent reperfusion treatment either pharmacologic (thrombolytics) or transfer to the
catheterization laboratory for percutaneous coronary intervention (PCI). PCI is recommended
and should be started within 90 minutes if done on-site or 120 minutes if done at a third-party
facility. If PCI is not possible thrombolytics should be initiated within 30 minutes. Patients with
unstable angina and non-ST elevation myocardial infarction (NSTEMI) should be admitted for a
cardiology consultation and workup. Outpatient workup may be suitable for patients with stable
angina (Johnson & Ghassemzadeh, 2021).
Health Promotion:
Studies have indicated that heart health may be improved and heart attacks averted by
having a nutritious diet; engaging in physical exercise; keeping a healthy body weight, blood
pressure and cholesterol levels; and lowering or eliminating alcohol and smoking. Healthy diets
known to aid people with ACS, include the Mediterranean diet and a diet abundant in fruits,
vegetables, whole grains, and seafood, with reduced salt and sugar. Simply eating a good diet
and restricting alcohol decreases heart attack risk by one-third. A healthy diet, moderate alcohol
consumption, moderate exercise (4-5 hours per week), smoking cessation, normal blood pressure
and cholesterol levels. Adherence to medications are effective in reducing chances of having
another heart attack, this include antiplatelet, anticoagulants, and lipid-lowering medications.
(Freiheit, 2015).
Follow-Up:
Anyone who has had a heart attack needs both cardiac rehabilitation and regular follow-
up by a physician or experienced practice nurse. Annual blood pressure checks, a blood test for
cholesterol and renal function, and a prescription review should all be part of this.
If the patient has been admitted, instruct the patient to see his Cardiologist seven (7) days
after discharge.
REFERENCES
American Heart Association (2015, July). Acute Coronary Syndrome. Retrieved March 22, 2022,
from [Link]
coronary-syndrome
Centers for Disease Control and Prevention (2021, January). Heart Disease: Heart Attack.
Retrieved March 22, 2022, from [Link]
Coven, D., Kalyanasundaram, A., Shirani, J. (2020, September). Acute Coronary Syndrome
Clinical Practice Guidelines. Retrieved March 22, 2022, from
[Link]
Freiheit, D. (2015, December). Acute Coronary Syndrome: How to Empower Patient. Retrieved
March 22, 2022, from [Link]
how-to-empower-patients
Johnson, K. & Ghassemzadeh, Z. (2021, August). Chest Pain. Retrieved march 22, 2022, from
[Link]
Roth, E. (2018, September). Chest Pain and GERD: Assessing your Symptom. Retrieved March
21, 2022, from [Link]
Spangler, S. (2019, April). Acute Pericarditis. Retrieved March 22, 2022, from
[Link]
