What is the appropriate admission order for a patient presenting with chest pain and dizziness?

Sample Admission Order for Patient with Chest Pain and Dizziness

Admit this patient to a monitored bed (telemetry or step-down unit) with continuous cardiac rhythm monitoring, as chest pain with dizziness represents a potential acute coronary syndrome requiring immediate evaluation and observation. 1

Admission Status and Location

• Admit to: Telemetry unit or step-down unit with continuous ECG monitoring 1
• Admission diagnosis: Chest pain with dizziness, rule out acute coronary syndrome
• Code status: Confirm with patient/family
• Condition: Stable (or specify if unstable)

Vital Signs and Monitoring

• Continuous cardiac rhythm monitoring 1
• Vital signs every 4 hours (or more frequently if unstable) 1
• Continuous pulse oximetry 1
• Notify physician for:
  • Chest pain recurrence 1
  • Systolic BP >180 or <90 mmHg 1
  • Heart rate >120 or <50 bpm 1
  • Oxygen saturation <90% 1
  • Any arrhythmias 1

Activity

• Bed rest with bedside commode privileges initially 1
• May advance activity as tolerated if patient remains stable and pain-free 1

Diet

• NPO until ruled out for urgent cardiac catheterization, then cardiac/heart-healthy diet 1
• Low sodium, low cholesterol diet once cleared 1

IV Access and Fluids

• Establish and maintain IV access 1
• Normal saline at keep-vein-open rate (or specify rate based on patient status) 1

Medications

Immediate/STAT Orders:

• Aspirin 162-325 mg PO now (if not already given in ED and no contraindications) 1
• Nitroglycerin 0.4 mg sublingual every 5 minutes × 3 doses PRN chest pain 1
  • Call physician if pain persists after 3 doses 1
• Supplemental oxygen 2-4 L/min via nasal cannula if oxygen saturation <90% or respiratory distress present 1

Scheduled Medications:

• Beta-blocker (e.g., metoprolol 25-50 mg PO every 12 hours) - initiate within first 24 hours if no contraindications (no heart failure signs, no low-output state, no increased cardiogenic shock risk, PR interval <0.24 seconds, no second/third-degree heart block, no active asthma) 1
• Statin (e.g., atorvastatin 40-80 mg PO daily) 1
• ACE inhibitor or ARB if indicated based on blood pressure and renal function 1

PRN Medications:

• Morphine sulfate 2-4 mg IV every 5-15 minutes PRN severe chest pain not relieved by nitroglycerin 1
• Antiemetic (e.g., ondansetron 4 mg IV) PRN nausea 1

Diagnostic Studies

STAT/Immediate:

• 12-lead ECG STAT and with any recurrence of chest pain 1, 2
• Cardiac troponin (high-sensitivity if available) STAT and serial measurements (typically at 0,3, and 6 hours or per institutional protocol) 1, 3, 2
• Complete metabolic panel (electrolytes, renal function) 1
• Complete blood count 1
• Coagulation studies (PT/INR, PTT) 1
• Lipid panel (if fasting) 1
• Brain natriuretic peptide (BNP) if heart failure suspected 1

Within 30 Minutes:

• Portable chest X-ray 1

Additional Testing (as indicated):

• Echocardiogram to assess left ventricular function and wall motion abnormalities 1
• Stress testing (exercise or pharmacologic) if serial troponins negative and patient remains low-risk 1, 4
• Coronary angiography if high-risk features present (elevated troponin, ST-segment changes, hemodynamic instability, recurrent ischemia) 1

Consultations

• Cardiology consult - for risk stratification and determination of invasive vs. conservative strategy 1
  • Request urgent/emergent consultation if: elevated troponin, ST-segment depression, hemodynamic instability, recurrent chest pain, or high-risk features 1

Special Instructions

• Notify physician immediately for: 1, 2
  • Recurrent or persistent chest pain
  • New ECG changes
  • Hemodynamic instability
  • Arrhythmias
  • Elevated troponin levels
• Serial ECGs with any symptom recurrence 1
• Patient should call nurse immediately for any chest discomfort, shortness of breath, palpitations, or dizziness 3, 2

Disposition Planning

• Determine invasive vs. conservative strategy based on risk stratification 1
• If low-risk with negative serial troponins and negative stress test: consider discharge with outpatient cardiology follow-up within 72 hours 1
• If high-risk features: proceed with coronary angiography 1

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Key Pitfall to Avoid: Do not delay ECG acquisition beyond 10 minutes of arrival or transfer for troponin testing in the office setting - these patients require immediate ED evaluation. 1, 2 The combination of chest pain and dizziness warrants serious consideration of ACS, particularly in older patients where dizziness may be an anginal equivalent. 1, 3