Here is an interesting case submitted by Adam Frederick, NREMT-Intermediate. As usual, some details have been changed to protect patient confidentiality.
EMS is called to the local Urgent Care for a 63 year old male complaining of upper jaw pain related to "dental work". He had made two trips to the dentist this past week for pain related to "work done on a crown". Both times the dental work was in order, and the dentist could not find a reason for the jaw pain. Today, while walking on the treadmill at the local fitness center, the jaw pain returned. He drove to urgent care because the dental office was closed.
While at urgent care, he reported to the nurse that the pain began about 45 minutes ago, and seemed to worsen when he did strenuous activity. He thought it odd that today he had some chest discomfort as well, but felt it was probably due to his anxiety.
EMS arrives to find the patient in exam room 2. He looks pale, and his skin is cool and moist. He reports jaw pain of 8/10, and substernal chest pain of 4/10. History is significant for hypertension and anxiety. He takes Lipitor, ASA, and Metoprolol daily. He has no known allergies. His vitals are as follows:
- HR: 90 and regular
- BP: 180/114
- RR: 16
- Skin: cool/moist/pale
- Lungs: clear bilaterally
- Spo2: 98% on supplemental oxygen
You apply your cardiac monitor and acquire the following rhythm strip and 12 lead ECG:
Prior to EMS arrival, the patient was given 4 baby aspirin, but now refuses nitro and the IV. He states he "doesn't know what all the fuss is about", and that he "just wants to go home", and you get the feeling that he just might refuse transport.
- What do you tell your patient?
- Are you concerned about the ECG? If so, why?
- How would you treat this patient, and where would you like to take him?