Chest pain

SBAR – Chest Pain / N/V

S – Situation:
38-year-old woman with extensive cardiac, renal, and chronic pain history presenting with recurrent acute chest and epigastric pain associated with nausea/vomiting.

B – Background:
PMH significant for:

• STEMI s/p PCI to LAD D1 (5/2024), known LCx CTO and mild–moderate RCA dz, CABG (2023)

• ESRD on HD (MWF), tertiary hyperparathyroidism, renal osteodystrophy, metastatic calcinosis

• DM2, gastroparesis, GERD

• Non-healing left thigh wound, L foot partial metatarsal amputation (2/2025) with revision (4/2025)

• T8 spinal fracture with paraspinal hematoma

• Chronic pain with frequent hospital visits

• MDD, insomnia, constipation

ED Workup:

• EKG: No acute ischemic changes

• Troponin: Flat

• Lipase: Normal

• CTA chest/abdomen: No acute aortic abnormality

A – Assessment:

• Recurrent acute on chronic chest and epigastric pain with N/V — likely related to chronic pain + gastroparesis; ACS less likely given flat trop and non-ischemic EKG.

• Hypertensive urgency

• ESRD on HD – incomplete HD session today per patient

• CAD s/p CABG/PCI – stable

• Gastroparesis, GERD, chronic pain, MDD, insomnia, constipation – ongoing management needs

R – Recommendation / Plan:

Pain / Chest-Epigastric Symptoms

• Reglan TID with meals

• Pantoprazole daily

• Pain regimen: scheduled Tylenol, tizanidine 2 mg daily (ESRD max), gabapentin 300 mg qHS (ESRD max)

• Dilaudid PRN overnight

• Consider Pain Management consult

• Clear liquid diet, advance as tolerated

Hypertensive Urgency

• Resume home: Amlodipine, Coreg, Clonidine, Imdur, Losartan

Gastroparesis

• PRN Reglan, PPI

• Has GI follow-up in January

ESRD on HD

• Nephrology to see in AM

• Resume home meds

CAD s/p PCI/CABG

• Continue ASA and Brilinta (may discontinue Brilinta — >1 yr post-PCI, confirm with cardiology)

MDD

• Continue sertraline 50 mg daily

• Depressed mood, consider psych consult; denies SI/HI

Insomnia

• Continue melatonin 6 mg nightly

• Continue trazodone 25 mg nightly

Constipation: Senna + MiraLAX PRN
GERD: Pantoprazole 40 mg daily
FEN: Clear liquids
PPx: SQH
Code Status: Full Code