What is the appropriate workup for a 32-year-old female presenting with slight pain in her left arm for one week, now experiencing sharp chest pain?

From the Guidelines

For a 32-year-old female presenting with left arm pain for a week and now experiencing sharp central chest pain, an immediate cardiac evaluation is recommended, as the combination of arm pain radiating to the chest is concerning for acute coronary syndrome, even in a young female 1. The patient should be sent to the emergency department for a comprehensive workup including:

• An ECG to evaluate for signs of ischemia or infarction
• Cardiac enzymes (troponin) to assess for myocardial damage, as high-sensitivity cardiac troponins are the preferred standard for establishing a biomarker diagnosis of acute myocardial infarction 1
• Complete blood count and basic metabolic panel to evaluate for other potential causes of chest pain
• Chest X-ray to evaluate for pulmonary causes of chest pain Additional tests may include a D-dimer to rule out pulmonary embolism and possibly a CT angiogram of the chest. While awaiting transport to the ED, administer aspirin 325mg to chew and swallow if not contraindicated, as early administration of aspirin has been shown to improve survival in patients with myocardial infarction 1. The patient should not drive herself to the hospital and should be transported via ambulance if available, as this will allow for prompt medical attention and evaluation. Other potential causes of chest pain, such as pulmonary embolism, aortic dissection, or musculoskeletal issues, should also be considered, but the presentation warrants ruling out life-threatening cardiac conditions first 1.

From the Research

Initial Assessment

The patient presents with slight pain in the left arm for about a week, now having sharp pain in the center of the chest. The initial assessment should focus on determining the cause of the chest pain, which could be due to various etiologies, including cardiac, pulmonary, or musculoskeletal causes.

Cardiac Causes

• The patient's symptoms could be indicative of acute coronary syndrome (ACS), which requires prompt evaluation and management 2.
• The evaluation of patients with suspected ACS involves obtaining a history, physical examination, electrocardiograms (ECGs), and cardiac troponin measurements in conjunction with risk calculators.
• A normal ECG result does not exclude ACS, and troponin levels can be elevated in many conditions.

Triage and Management

• The patient should be triaged according to the severity of their symptoms, and those with suspected ACS should receive aspirin, if not contraindicated, as soon as possible 2.
• Patients with ST-segment elevation myocardial infarction (STEMI) or those without STEMI who are in unstable condition should be triaged to undergo reperfusion therapy, typically via percutaneous coronary intervention (PCI), within 120 minutes of first medical contact.
• If the patient must be transferred to a PCI-capable facility, fibrinolytic therapy should be initiated within 30 minutes of presentation if STEMI is present.

Other Considerations

• The patient's symptoms could also be due to non-cardiac causes, such as musculoskeletal or pulmonary etiologies.
• A thorough evaluation, including a physical examination and diagnostic tests, is necessary to determine the underlying cause of the patient's symptoms.
• The use of structured primary assessment tools, such as the Emergency Severity Index (ESI) or the Manchester Triage System (MTS), can help to categorize the urgency of the patient's condition 3.