You just finished rounding in the critical care area at Janus General Hospital when the triage nurse wheels over a patient from walk-in triage. The patient is a 75 year old male with a history of well controlled hypertension presents to the ED complaining of chest pain. The pain is located in the center of his chest, started suddenly last night after going to bed, he describes it as “my chest is on fire”, no radiation, 20/10, nothing makes it better or worse, but he hasn’t tried taking anything for it. The only associated symptom is nausea, but no vomiting. No history of smoking.
VS: 175/90 P:90 R:20 T:98F SpO2:99%
Exam: Uncomfortable looking older male, looks younger than stated age with epigastric tenderness. The remainder of the exam is unremarkable. EKG shows sinus rhythm with no ST or T-wave changes. In fact, the computer reads it as “Normal EKG”. You get the chest x-ray above.
Interpret the image. What is on your differential? What is likely? What can kill the patient? What are your next steps in management?
Special thanks to Dr. Wang.