Chapter 42 Chest Pain (Case 27)
Postoperative context: A 67-year-old man develops chest pain on postoperative day 2 after a sigmoid colectomy for diverticulitis.
PATIENT CARE
Clinical Thinking
• First r/o the immediate life-threatening cardiopulmonary complications. MI can occur anytime, yet frequently presents on POD #2 or #3 after major surgery. Suspicion for pulmonary embolus (PE) should be high in any surgery patient, especially those with multiple risk factors for deep venous thrombosis (DVT).
History
• Characterize the pain by site, radiation, and nature. The timing of the pain is also important from onset, duration, and prior episodes of similar symptoms.
• MI is often described as a “heaviness” or “crushing” chest pain that may radiate to the jaw or left arm. PE will often present with shortness of breath as well. These patients may or may not have a hx of DVT. Chest pain is not common in pneumonia, but a hx of prior lung disease or aspiration during anesthesia predisposes to pulmonary infection. Spontaneous pneumothorax is unlikely, but consider recent thoracic procedures, including central line insertion. A thorough hx of prior symptoms will elucidate the likelihood of chest pain from gastroesophageal reflux or anxiety.
Physical Examination
• Stop and look. Inspection from the end of the bed can often hint to the severity of the acute process and whether or not ICU transfer is necessary. A pale, diaphoretic, and tachypneic patient may point towards MI and the ICU.
• VS: Tachycardia may accompany all possible entities. Fever and tachycardia are suspicious for PE, although physical examination findings in PE are often unremarkable. Hypotension may represent massive PE or MI. Oxygen desaturation more likely indicates PE, pneumonia, or pneumothorax.
Tests for Consideration
| $35 | |
| $32 | |
| $35 | |
| $115 | |
| $65 | |
| $125 |
