Jack is a 28 yr old sedentary male: pale, thin (non smoker) with a history of anxiety and unexplained chest pain and tachycardic events. He has had one event of SVT recorded on 24hr holter. All other events seen in ER have been sinus rhythm. He lives at home with his parents who care for him. He rarely goes out the home due to extreme fatigue, dizziness and a flu like feeling which he attributes to his condition . He is not depressed and has been refered to the local mental health team who report he has Chronic Fatigue Syndrome and associated Dysautonomia, (presumed to be due to inactivity). There is little on offer in terms of treatment - apart from a raised pulse of 90 sitting and a pronounced tachycardia upon standing, - all clinical observations are unremarkable. He has previously undergone an Angiogram in the past, which was normal. Before the procedure, Jack reported he felt rather freaked out and a supine pulse of 120bpm was observed. Of note was the procedure was stopped half way through due to an inappropriate sinus tachycardia (IST) of 170bpm before LV could be assessed. He was given IV Midazolam as a sedative and the procedure stopped. The cardiologist at his previous Hospital feels confident Jack does not suffer from CHD due to his age, normal BP, saturation readings, no signs of oedema, normal diet. He does not wish to repeat the procedure for safety reasons. Jack is admitted to Hospital several months later at midnight following a complaint of sudden onset severe chest pain, shortness of breath and tachycardia. He reports he was not exerting at the time of onset and was simply sitting at his computer . On admission, he appears nervous, keen to explain his symptoms in detail and wants to know when it will stop . He sees a Doctor at approx 12.30 am as a priority 2 case. Supine his observations were as follows: --------------------------------------... Heart rate 135 bpm Blood pressure 169/142 Respiration rate 16 Sa 02 is 99% Peak flow reading 450 (predicted 640). Q Wave II amp; III changes are shown on ECG Chest clear: A/t = bilaterally Temp: 36.5 Awake amp; Orientated Complaint: --------------- C/O tight chest pain centrally radiating to the back. Anxious ++ Diagnosis: --------------- Chest tightness, tachycardia amp; hypertensive on admission. Gradually settled. Given 5mg Diazepam (refused 10mg). Still appears anxious amp; describes symptoms of anxiety very well, but denies any psychiatric problem. ECG = Sinus tachycardia (I think Q wave was due to anxiety?). Refer to family doctor only. --------------------------------------... QUESTION: Jack denies he is having a panic attack and insists he has a physical problem, despite admitting feeling very anxious due to his symptoms. He remains calm and polite, yet the medical staff are concerned at his diastolic readings which are abnormal and do not wish to discharge him until this has settled. 5mg Diazepam is given to Jack orally after his sustained hypertension and chest pain is observed for 30 mins in triage. He takes approximately 2 hours to feel calmer and report his chest pain has resolved. He says the medication has made him feel stoned and sleepy . 30 mins later, his observations are: --------------------------------------... Heart rate 128 bpm Blood pressure is 138/85 The medical staff feel it is now safe to discharge Jack back home and feel a referral is un-necessary. He has been in Hospital triage - 2hrs 30 mins. In less than 300 words explain: --------------------------------------... A) If you refer him for Psychiatric or Cardiac Review before discharge. b) Note why you think Q waves changes are important in your decision. c) Diazepam reduced hypertension amp; chest pain in Jack. Why? d) Is there any real evidence of Ischemic pain in the absence of CHD? e) Is Jack presenting with an IST or a Tachycardia due to anxiety? --------------------------------------... Thank you - tough one, huh?!
Well my answer isn t going to be 300 words, I ll leave that to you. His cardiac symptoms have not been adequately evaluated. Perhaps he needs to have a stress cardiolyte.. His BP and heart rate are high and of great concern. I would do a work up for the cause of his hypertension. You state he is calm and but his BP swings from quite high to normal. I ve seen this before in patients who have phenochromocytoma, a tumour on his adrenal glands.Since he has had a prolonged episode of chest pain why didn t they draw bloodwork and check his cardiac enzymes. They should of done a Troponin test at least. To send him home without doing that is negligence. He should also have a CBC done incase he is anemic.His inferior Q wave changes are a source of concern, did he have a previous MI. He hasn t had an echocardiogram to look for any structural problems with his heart or a stress test. The stress test would be difficult because of his high heart rate, they could try a stress cardiolyte..Anxiety can be a normal reaction to his physical symptoms and the Valium just helped to relax him. Since his angiogram was quot;normalquot; I can understand why the cardiologist ruled out any problems with his heart but he could have syndrome x or (it s a stetch), coronaryartery spasm. He has been diagnosed with IST perhaps he should be reffered to a cardiac electrophysiologist for assessment of this problem. There are no ecg changes of ischemia on the ecg. Regarding psych, only after he has had all investigation of his cardiac problems. I am not familiar with a refferal for quot;Cardiac Reviewquot; He does have a documented arrythmia and unstable BP so yes, it sounds like he needs all the suport he can get to be less anxious.He has a documented arrythmia which I feel is made worse by his anxiety. I would not discharge him without knowing the results of at least 2 sets of cardiac enzymes are negative. Q waves are also important because they indicate the possibility of an old myocardial infarct. He should be closely monitored by his family Dr,who should investigate his hypertension symtoms.Take care, Donna
id be worried re a Pulmonary Embolus causing his tachcardia and Q waves
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