Final answer:
In this case, the patient presents with sudden-onset severe substernal chest pain that radiates to the jaw and shoulder, accompanied by shortness of breath, and nausea. The most likely diagnosis is an acute myocardial infarction (heart attack). Emergency orders include oxygen administration, cardiac monitoring, and starting an IV line.
Step-by-step explanation:
In this case, the patient presents with sudden-onset severe substernal chest pain that radiates to the jaw and shoulder, accompanied by shortness of breath, and nausea. Based on the patient's history of stable angina, smoking, hypertension, and positive family history of heart disease, the most likely diagnosis is an acute myocardial infarction (heart attack).
Emergency orders:
- Administer oxygen to improve oxygenation.
- Place the patient on a cardiac monitor to monitor the heart's electrical activity.
- Start an IV line for access to medications.
Physical exam:
- Assess vital signs, including blood pressure, heart rate, and respiratory rate.
- Perform a detailed cardiac examination to assess for any abnormal sounds (murmurs) or irregular rhythms.
Diagnostic tests:
- Obtain an electrocardiogram (ECG) to evaluate the electrical activity of the heart.
- Order cardiac enzyme tests (troponin levels) to confirm the diagnosis of a myocardial infarction.
Therapy:
- Administer nitroglycerin sublingually to relieve chest pain.
- Start antiplatelet therapy, such as aspirin, to prevent further clot formation.
Location:
- The patient should be admitted to a hospital's cardiac care unit for further monitoring and treatment.
Final order:
- Consult a cardiologist for further management of the patient's acute myocardial infarction.
Dx:
- The diagnosis is confirmed as an acute myocardial infarction based on the patient's presentation and the diagnostic tests' results.