Option 2: Chest pain with stable vital signs

The patient appears mildly uncomfortable when you enter the room. The nurse hands you the ECG while he obtains a new set of vital signs. The ECG shows normal sinus rhythm with no abnormalities. The patient's blood pressure is 148/85 mm Hg, heart rate is 80 beats/minute, respiratory rate is 18 breaths/minute, and oxygen saturation is 98% on room air. You see that the patient already has IV access established and is hooked up to the telemetry monitor.

Question: What's your next step in evaluation and management?

Make your choice, then click on the explanation bubble to reveal the answer.

• Give a trial of nitroglycerin to see if her chest pain improves.
• Hand off the patient to night float because the ECG and vital signs are normal.
• Take a focused history to help narrow your differential diagnosis and guide further evaluation.

Although the patient is currently stable, you'll still want to keep serious causes of chest pain in mind.

Question: Can you name at least three potentially life-threatening cardiac and noncardiac causes of chest pain?

Think of your three, then click on the explanation bubbles to reveal some examples.

• Cardiac
• Noncardiac

If you need to expand your differential or make sure it's complete, check out “Causes of chest pain.”

A normal ECG does not rule out acute coronary syndrome. The ECG findings may evolve over time.

Your workup is based on the information you gathered during your review of the patient's records and your focused history.

Question: What studies should you order for most patients with undifferentiated chest pain?

Think of the studies you would like to order, then click on the explanation bubbles for more information.

• Laboratory studies
• Imaging
• Other

For more information, you can always reference “Management of chest pain.” And remember, you don't have to stay in the hospital to wait for all these test results. You can sign them out to night float (along with a reminder to reevaluate the patient).

Since this patient is stable, you have the luxury of taking your time with the physical examination in order to narrow your differential! So you can remember what you're looking for and easily identify any abnormalities in real life, take a few minutes now to review the examination videos below.

Cardiovascular examination findings

And there's lots more where that came from.

If you haven't explored the other scenario yet, jump over to “Option 1: Cardiac emergency.” You can also return to the main module to wrap up “Achy breaky heart.”