Reflective Writting

Management of the patient with acute chest pain

A 63-year-old woman presents to the ED at 2:00 a.m. complaining of nausea that began 3 hours ago. She denies any prodromal symptoms and has not had any vomiting, pain, or diarrhea. She states she and her husband had the same meal last night and that he is feeling well. She offers no other complaints. On arrival to the ED, she began vomiting.

Pastmedical history
The patient has a 10-year history of diabetes,which is treated with oral hypoglycemic medication.
In addition, she has a history of hypertension and elevated cholesterol. She quit smoking
5 years ago and drinks alcohol occasionally.

The patient’s medications include glypizide, lisinopril, and atorvastatin.

The patient has no known drug allergies.

Physical exam
Vital signs: temperature 36.2◦C, heart rate 55 bpm, blood pressure 102/71, respiratory rate
24, room air saturation 98%.

General: awake and alert, diaphoretic .
Head and neck: pupils are equally round and reactive to light, cranial nerves intact. The
patient’s mucous membranes are moist. Her neck is supple with a midline trachea. There
is no jugular venous distension.

Cardiovascular: regular bradycardia without murmurs or rubs, no third or fourth heart
sounds, peripheral pulses present throughout.

Lungs: clear.

Extremities and skin: trace bilateral edema, no clubbing, no calf tenderness. Her skin is
cool and clammy.

CXR: no acute changes.

Questions for thought

What are the appropriate initial actions to take to stabilize this patient?
What other diagnostic modalities are appropriate in the ED?
What therapeutic interventions are appropriate?
How does ED treatment differ based on the abilities of the institution?
What are indications for transfer?

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