An 82-year-old woman comes to the emergency department with sudden-onset epigastric pain. The pain started an hour ago and is 8/10 in severity. The patient has been nauseated and vomited twice in the past hour. Her past medical history includes type 2 diabetes mellitus, hyperlipidemia, hypertension, peptic ulcer disease 10 years ago, and cholelithiasis. She has a 40-pack-year smoking history and drinks alcohol occasionally. Her temperature is 36.8 C (98.2 F), blood pressure is 140/80 mm Hg, pulse is 90/min, and respirations are 14/min. The lungs are clear to auscultation. Abdominal examination shows a soft abdomen with no tenderness. Murphy's sign is negative. Which of the following studies should be performed first in this patient?

Question

An 82-year-old woman comes to the emergency department with sudden-onset epigastric pain.  The pain started an hour ago and is 8/10 in severity.  The patient has been nauseated and vomited twice in the past hour.  Her past medical history includes type 2 diabetes mellitus, hyperlipidemia, hypertension, peptic ulcer disease 10 years ago, and cholelithiasis.  She has a 40-pack-year smoking history and drinks alcohol occasionally.  Her temperature is 36.8 C (98.2 F), blood pressure is 140/80 mm Hg, pulse is 90/min, and respirations are 14/min.  The lungs are clear to auscultation.  Abdominal examination shows a soft abdomen with no tenderness.  Murphy's sign is negative.  Which of the following studies should be performed first in this patient?

Quizplus · Accepted Answer

11ec25c8_d182_7f77_bc81_5532412a3642_MD0003_00 An ECG is the essential first step in a patient with history and risk factors for coronary artery disease who has symptoms consistent with acute coronary syndrome (ACS). There are a number of well-known atypical presentations (ie, no overt chest pain) of ACS that should prompt a cardiac evaluation. Unfortunately, patients with atypical symptoms are more likely to have a delay in diagnosis and under-treatment, which contributes to worsened outcomes. Women, the elderly, and patients with diabetes in particular are more likely to have atypical symptoms; up to 20% of these patients do not report chest pain at the time of presentation. Dyspnea, epigastric pain, and nausea/vomiting are common atypical presentations. (Choices A, C, D, and E) Abdominal ultrasound is useful for diagnosing acute cholecystitis. Serum amylase and lipase are very helpful tests to support the diagnosis of pancreatitis. Upper gastrointestinal endoscopy should be considered in patients with evidence of acute gastrointestinal blood loss or in the evaluation of possible peptic ulcer disease (PUD). An upright abdominal x-ray would be helpful in diagnosing PUD complicated by perforation as air may be seen under the diaphragm. All may need to be considered in this patient but are less immediately life threatening; they should be evaluated after workup for a cardiac etiology has been initiated. Educational objective: Abdominal pain and nausea/vomiting are atypical presentations of acute coronary syndrome. In select patients, cardiac causes must be excluded prior to pursuing other etiologies. References: Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. (http://www.ncbi.nlm.nih.gov/pubmed/12486425) Sex differences in symptom presentation in acute myocardial infarction: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/22000678) Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/12140497)

An 82-Year-Old Woman Comes to the Emergency Department with Sudden-Onset