A patient comes in with substernal chest pain that is radiating to his left arm.

His EKG shows no ST elevation.

Which priority orders do you expect to see next from the health care provider to further evaluate this patient's chest pain?

Choice A rationale

Syncope, or transient loss of consciousness, in a patient with a pacemaker is often a sign of inadequate cardiac output, potentially due to a sudden drop in heart rate. This can happen if the pacemaker is malfunctioning or if the battery voltage has dropped below a critical level, indicating a need for urgent assessment and possible device replacement.

Choice B rationale

While infection is a risk and can cause systemic symptoms like fever and malaise, it is less likely to be the immediate and primary cause of acute syncope. Syncope suggests a hemodynamic issue, making direct assessment of the device's function and battery life a more critical initial step compared to checking for localized infection signs.

Choice C rationale

Recent dietary changes are generally not a direct, immediate cause of acute syncope unless they lead to severe electrolyte imbalances or hypoglycemia. Although nutrition is important for overall health, a pacemaker patient's acute syncope requires an initial focus on cardiac function and device performance over lifestyle changes.

Choice D rationale

A patient's medication history can certainly contribute to syncope (e.g., hypotension from antihypertensives). However, in a patient with a pacemaker, the most likely cause of an acute syncopal episode is device malfunction or battery depletion, making the assessment of the pacemaker's electrical integrity the highest priority. —. ##.

Choice A rationale

Atrial fibrillation is characterized by chaotic, irregular electrical activity in the atria, leading to an irregularly irregular ventricular rhythm. The EKG would show an absence of clear, distinct P waves, which are replaced by chaotic fibrillatory waves, and R-R intervals that vary significantly, unlike a regular rhythm strip.

Choice B rationale

Sinus tachycardia is a rhythm originating from the SA node with a regular rate greater than 100 beats per minute (bpm). A 6-second strip, showing R-R intervals, would demonstrate a regular rhythm with a rate above 100 bpm, and a P wave preceding every QRS complex.

Choice C rationale

Paroxysmal Supraventricular Tachycardia (PSVT) is a rapid rhythm, usually 150-250 bpm, characterized by regular R-R intervals. P waves are often hidden within the preceding T wave or QRS complex, or may appear abnormal, and the rate is significantly faster than the rhythm strip likely demonstrates.

Choice D rationale

Sinus bradycardia is a regular rhythm originating from the SA node with a heart rate less than 60 beats per minute (bpm). The EKG would display a P wave before every QRS complex, a regular rhythm, and R-R intervals that are long, indicating a slow rate, which is inferred by the widely spaced complexes. —.