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 & III changes are shown on ECG
Chest clear: A/t = bilaterally
Temp: 36.5
Awake & Orientated
Complaint:
—————
C/O ‘tight’ chest pain centrally radiating to the back.
Anxious ++
Diagnosis:
—————
Chest tightness, tachycardia & hypertensive on admission. Gradually settled. Given 5mg Diazepam (refused 10mg). Still appears anxious & 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 & 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?!
Tags: angiogram, bpm, cardiologist, chest pain shortness of breath, chronic fatigue syndrome, clinical observations, extreme fatigue, heart rate, inappropriate sinus tachycardia, local mental health, mental health team, midazolam, respiration rate, safety reasons, sedative, shortness of breath, sinus rhythm, sudden onset, supine, tachycardic
