Medical Emergencies · patient case with 2 questions
Chest pain in a patient with reflux and cardiac history
Patient: Adult with multiple medical problems
Chief complaint: Substernal pain radiating to the shoulder, beginning in the chair.
Background: Gastro-oesophageal reflux disease on medication. Hypertension. Known cardiac history and dyspepsia.
Vital signs / labs: Vital signs normal. No arrhythmia detected.
Current findings: Pain is substernal and radiates to the shoulder.
Question 1
What is the most likely diagnosis?
Show answer and explanation
Correct answer: B. Angina pectoris
- A. Reflux is a genuine differential given his history, and the distinction is clinically difficult — but radiation to the shoulder points to cardiac origin, and the safe assumption is cardiac.
- B. CORRECT. Substernal pain RADIATING TO THE SHOULDER is the classic description of cardiac ischaemia. Radiation to the left arm, shoulder, jaw or neck is what distinguishes angina from reflux, and given his known cardiac history this must be assumed cardiac until proved otherwise. Reflux may mimic it, but you cannot afford to make that assumption in the chair.
- C. A panic attack may cause chest tightness but would not be the working assumption in a patient with established cardiac disease.
- D. Syncope is transient loss of consciousness, which is not described.
Question 2
What is your immediate management?
Show answer and explanation
Correct answer: B. Stop treatment, position him comfortably, give oxygen and administer his nitroglycerin
- A. Continuing any treatment during an episode of possible cardiac ischaemia is indefensible.
- B. CORRECT. Stop, position the patient upright or semi-upright for comfort, give oxygen, and administer sublingual nitroglycerin, monitoring vital signs. If the pain does not resolve after three doses at five-minute intervals, treat it as a myocardial infarction: activate emergency services and give aspirin to chew, unless contraindicated.
- C. Glucose is the treatment for hypoglycaemia, which does not present in this way.
- D. Trendelenburg is used for syncope. In cardiac chest pain it increases venous return and cardiac workload, and worsens breathlessness.
Note: Sequence worth memorising: stop, position, oxygen, nitroglycerin. If unresolved after 3 doses over 15 minutes, treat as myocardial infarction — call emergency services and give aspirin to chew.