CARDIOLOGY

GENERIC CHEST PAIN MDM

Cardiac risk factors, labs, EKG and imaging were reviewed. EKG shows no acute ischemic changes. Trop x 1 is negative, symptom onset > 6 hrs PTA. /// Troponin x 2 negative. /// HEART Score is XXXX therefore patient is considered low risk for MACE within 30 days and is thus safe for d/c with outpatient cardiac f/u. Unlikely PE as pt is PERC negative///dimer is negative///CTA chest is negative. Unlikely PTX as pt has b/l breath sounds and CXR is negative for ptx. Unlikely PNA as pt is afebrile with no PNA seen on CXR and without PE findings c/w PNA. Unlikely tamponade as there is no low voltage on EKG or CM on CXR. Unlikely pericarditis, endocarditis or myocarditis based on risk factor analysis, EKG and lab findings and the lack of fever. Unlikely aortic dissection or aneurysm based on history (not abrupt in onset, no tearing/ripping), physical exam (pulses symmetric), and lack of mediastinal widening on CXR. Unlikely Esophageal rupture as the CXR is unremarkable and there is no dysphagia. Unlikely zoster as there is no appreciable rash.

New Onset AFIB MDM
Given their history and exam it is likely this patient is spontaneously reverting to a rate controlled rhythm but necessitates a thorough workup for their new arrhythmia.
Workup: ECG, CXR, CBC, BMP, UA, Troponin, BNP, TSH, Ca-Mag-Phos
Findings: ECG:
Interventions: Defer Cardioversion (uncertain historical reliability with time of onset, increased risk of thromboembolic stroke).
CHADS VASC score: ___

Patient’s presentation not consistent with Pneumothorax, Pneumonia, Pulmonary Embolus, Tamponade, ACS, Thyrotoxicosis. No history or evidence decompensated heart failure.
Reassessment: Patient maintained NSR during multi-hour observation in ED.
Rx: Xarelto 20mg Daily (Denies hemophilia, recent GI or other ongoing bleeding), Metoprolol 25mg BID, Aspirin 81mg daily
Disposition: Discharge home with prompt PCP follow up and cardiology referral.

CHEST PAIN D/C INSTRUCTIONS

You have been evaluated in the Emergency Department today for chest pain. Your evaluation was not suggestive of any emergent condition requiring medical intervention at this time. Your EKG did not show any acute changes. 
Please follow up with your primary care physician as needed. If you do not have a primary doctor, you can call your insurance company to find one.  If you do not have insurance, you can go to the finance/registration department for more assistance.
Return to the ER immediately for worsening chest pain, palpitations, shortness of breath, persistent vomiting, fainting, or for any other concerning symptoms. 

Elevated BP was addressed with the patient. Will refer to PCP for continued BP monitoring and management. I also recommended several lifestyle modifications (weight loss, dietary sodium restriction, increase physical activity and moderate alcohol consumption).

This patient has a low risk of a significant etiology causing their syncope given that their age less than 60, they have no family history of sudden death, and have no history of CHF, CAD, congenital heart disease or ventricular arrhythmias. Also, the circumstances surrounding the syncopal event are not consistent with ACS and there is no current evidence of CHF or valvular heart disease, no significantly abnormal ECG, nor exertional syncope. Using prediction rules for syncope, this patient is safe for discharge and outpatient evaluation. 

The patient was immediately placed in monitored bed, and IV was placed, oxygen was administered, and the EKG was evaluated. The ECG revealed an acute ST elevation myocardial infarction. A code STEMI was called XXX time and the cath lab was activated. I spoke with DR. XXX of cardiology who agreed to take this patient directly to cardiac catheterization. Defibrillator pads were placed on the patient. The patient was given Aspirin and Plavix. After a chest x-ray was performed which showed no mediastinal widening IV heparin was given based on the patients weight. The patient had normal hemodynamics during the ED course and was taken directly to the cardiac cath lab.