APPENDIX 1 – THE SCENARIOS
1. 38 y/o man presents with substernal chest pain x 2 days. The pain is present most of the day at a level of 4-6/10. The pain is sharp without radiation. The patient has no diaphoresis, shortness of breath or other associated symptom. The pain is not provoked by walking, activity or food. The patient exercises routinely and has never had exercise induced chest pain. He has never had a stress test. He comes to the Emergency Department because the pain has not gotten any better and his boss at work insisted he come "get checked out"
PMHx: None, no family history of premature coronary disease
Social Hx: No tobacco, no ETOH, no cocaine or other drugs
Vital Signs: BP: 136/80 Pulse: 82 Respiratory Rate: 16 Temperature: 37.0 Pulse Oximetry: 99%
Physical Exam: No Abnormalities noted, pain is not reproduced with palpation of the chest.
ECG - NSR, no evidence of ischemia
CXR - Normal
Laboratories: CBC, Chem7, UA are Within Normal Limits. Initial Troponin is <0.03 (normal).
2. A 44 year old man presents with sharp, non-radiating mid-sternal chest pain for 4 hours after smoking cocaine 5 hours ago. The pain has been constant and gradually worsening. It is now 8/10. He had some palpitations when the pain began but these have resolved. He denies nausea, diaphoresis, shortness of breath, cough or headache. He has had some mild chest pains and palpitations after smoking cocaine previously but did not seek medical care. He came to the Emergency Department this time because the pain has never been this intense or lasted this long. He has not seen a physician in 5 years and has never had a cardiac evaluation.
PMHx: Noncontributory, no known CAD, DM, HTN, hypercholesterolemia or Family History
Social Hx: Uses Cocaine about once weekly. Smokes 1/2ppd Rare Alcohol . No IVDU
Vital Signs: BP 148/90 Pulse: 104 RR: 16 Temp: 37.4 Pulse Ox 100%
Physical Exam: The patient appears mildly uncomfortable. He is mildly flushed and occasionally winces during the examination. He is mildly tachycardic but has no murmurs rubs or other abnormal heart sounds. Chest is clear and pain is not particularly reproducible. The remainder of the exam is unremarkable.
ECG: NSR. No evidence of ischemia
CXR: Normal
Labs: CBC, Chem7, CPK and UA are Within Normal Limits. Troponin is <0.03 (normal)
3. 67 y/o with hx CAD (MI with stent 3 years ago) with left sided, sharp chest pain for 1 day. The pain started this morning when he awoke (about 12 hours ago). The pain is very different from his previous angina but is very painful (9/10). The patient points to a small area near his left nipple as the site of the pain. He has no associated SOB, lightheadedness, and diaphoresis. The pain has not been related to walking or climbing stairs but is exacerbated by some arm movements. The patient called his primary care provider about the pain and was advised to come to the Emergency Department for evaluation. He had a normal Stress Echocardiogram 1 year ago.
PMHx: CAD, Hypercholesterolemia (on Atorvastatin)
Social Hx: Ex Smoker (quit 3 years ago), no alcohol, no drugs
Vital Signs: BP: 132/72 Pulse: 64 RR: 16 Temp: 36.6 Pulse Ox 100% on Room Air
Physical Exam: The patient is in no distress and well-appearing. His Cardiac exam is normal. Chest examination reveals a tender area just below the L nipple that reproduces the pain. There are no skin findings. The remainder of the physical exam is normal.
ECG: NSR, Q waves in leads II, III, AVF, No ST segment changes. (The ECG is unchanged from an ECG obtained 1 year ago during a follow up visit).
CXR: Normal
Laboratories: CBC, Chem7, UA are Within Normal Limits. Initial Troponin is <0.03 (normal)
4. 48 y/o perimenopausal woman with DM presents with fatigue, nausea and chest discomfort for one day (about 24 hours). She describes the chest pain as "fullness." She states the chest fullness is 5/10 and has been present most of the day but has come and gone somewhat. She complains about nausea but this does not seem to her to be coincident with the chest fullness. She reports no diaphoresis, no fever, no syncope, no palpitations, no shortness of breath, and no abdominal pain. The pain is not exertional. The pain is not particularly related to eating. She had a negative stress echocardiogram 3 years ago when she was evaluated for shortness of breath.
Vital Signs: BP: 126/70 Pulse: 78 RR: 16 Temp: 37.0 Pulse Ox: 98% on Room Air
PMHx: DM (takes Metformin), Borderline Hypertension (on Lisinopril)
Physical Exam: Well appearing, NAD, Chest and Cardiac exam are unremarkable. There is minimal epigastric tenderness.
ECG: NSR, Flat T waves in V5, V6. No ST segment changes.
CXR: Normal
Laboratories: WBC 9.0 K (67% PMN) , Hb 12.2, Na: 137 K: 4.2 HCO3: 24 BUN: 12 Cr: 1.2 Glucose: 186, LFTS: Normal, Lipase: Normal, Troponin <0.03 (negative)
5. 54 y/o man presents to the Emergency Department with sub-sternal chest pressure radiating to L arm x 4 hours. Pain has been on and off typically lasting between 10 and 30 minutes. The pain ranges in intensity from 4/10 to 7/10. The patient had a similar feeling 3 days ago that resolved with rest after about 20 minutes. He denies shortness of breath, diaphoresis or palpitations but does feel weak when the pain is intense. He denies any exertional component to the chest pain and denies any change in pain with arm movement. He has never had a stress test.
PMHx:
Vital Signs: BP 144/88 Pulse 88 RR 16 Temp 36.7 Pulse Oximetry 99% RA
Physical Exam: Patient is in mild distress, rubbing left arm. Lungs are clear and cardiac exam is normal. Remainder of the examination is normal
EKG: NSR, Inverted T waves in V4, V5, V6. No ST segment abnormalities. No prior ECG is available for comparison.
CXR: Normal
Laboratories: CBC, Chem7, UA are Within Normal Limits. Troponin is <0.03 (normal)
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