1. !

2. You are on call….

5. You get the page…62601 3 West is calling--- Nurse: – “Mr. Jones in 3201 has chest pain” – “What should I do student doctor?” You: – in your mind “seriously, you are asking me?” – Out loud: “Okay, let’s find out more….”

6. What do I want to know? Look at your sign out sheet to get the background history of the patient 72 year old with diabetes, hypertension admitted with feeling weak for 3 days. Here I am admitting another patient in the ER. How do I prioritize?

7. Ask the nurse some questions How does he look? – Remember that thing called general appearance? What are the vitals signs? – They will not automatically get these, you may have to ask. – Vitals signs are helpful! (They are vital!) – BP of 200/100 vs. 120/80 – BP of 80/50 vs. 120/80 – Pulse 140 vs 30 vs 85 – Oxygen saturation on room air or oxygen – Does RR help? In theory-----

8. T 36.8, P 92, BP 120/80, ox sat 96% on RA So these appear stable. I can breathe for the moment…. What do I do next to figure this out? What is my ddx of chest pain in a 72 yo diabetic with htn who is in the hospital and feeling weak? – 1. – 2. – 3. – 4. – 5.

9. So with that ddx in mind, what tests might I order that can be done while I am walking up there EKG Chest xray Blood pressure in both arms Labs---which ones? – CBC – Cardiac enzymes

10. He looks like this- what does this make you think of?

11. If his ekg looks like this---what is going on?

12. His admission cxr looked like this—well sort of…

13. What if his CXR looks like this now?

14. Remember—think of your ddx of the symptom!

15. You leave 3 west, and go back to the ER. 20 mins later the pager goes off 62601 “Ms. Smith has chest pain” Sign out sheet Ms. Jones is a 36 year old female who is POD#3 after a hysterectomy for fibroids.

16. Hmmm-what is differential here 1 2 3 4 5

17. Vitals: temp 37.5, P 120, BP 100/60, Ox sat 94% on RA

18. What labs, studies? 1 2 3 4

19. Here is her EKG

20. Vitals ABG: ph 7.49/ paO2 60/pC02 30

21. —92-year-old woman referred to clinic for possible pulmonary embolism. Cobelli R et al. AJR 2004;182:530-531 ©2004 by American Roentgen Ray Society

22. Call number 3 “Mr. Smith has chest pain. “ Signout: 57 year old male with hx of severe COPD who was admitted with an exacerbation. He has been on Bipap continuously and seems to be improving. Nurse says- he looks uncomfortable and is complaining of sharp pain in his right chest towards his shoulder. His oxygen sat is also lower.

23. Ddx in this patient? 1 2 3 4

24. What is the arrow pointing to?

25. So tips to remember: Think of your differential dx early Ask the nurse for some help- – Vitals, appearance, recent events Get some things cooking—labs, enzymes, cxr, ekg…. Oh---don’t forget about the patient…..

26. If he still looks like this---do something to help him feel better----

27. Good luck! Have fun! Learn a lot!