Clinical Case Study: Chest Pain & Acute Coronary Syndrome
We all imagine a heart attack as someone clutching their chest in agony, unable to breathe. But the truth is — especially in women, people with diabetes, and older adults — cardiac pain can be quiet, disguised, and easily mistaken for something far less serious. Missing those subtle signs is the last thing any of us want to do. This case study trains you to spot every presentation — not just the dramatic one.
📋 How to Use This Case Study
- Read through Jean’s story carefully — her presentation might surprise you.
- Write down your answers to all 4 questions before clicking anything. What would you prioritise? What would you say?
- Click “Reveal Answer & Rationale” to compare your reasoning against evidence‑based practice.
Patient Background & Clinical Narrative
Patient: Jean Campbell, 68 years old
Background: Known Type 2 diabetes, hypertension, high cholesterol. Admitted for observation after a minor fall. Usually active and independent. Her husband passed away recently and she’s been feeling low.
What You See: Evening round. Jean says she feels “a bit off” — tired, breathless, with a dull heavy ache across her upper stomach spreading into her jaw. She thinks it’s indigestion or stress. Pale, slightly clammy, breathing shallower than normal. Insists it’s “nothing to fuss about” and doesn’t want to bother anyone.
Assessment & Key Findings
- Discomfort: Dull ache — epigastric, radiating to jaw. Heavy, not sharp. Worse on slight exertion.
- Respiratory Rate: 24 breaths/min — shallow, breathless on movement
- SpO₂: 94% on room air
- Heart Rate: 106 bpm
- BP: 158/92 mmHg
- Appearance: Pale, cool, slightly clammy
- ECG & Troponin: Not yet done
Question 1: Atypical Presentation — Why It Matters
Jean doesn’t have “classic” crushing central chest pain. Why are women, diabetics, and older patients more likely to present differently — and why does this matter?
Answer: Autonomic nerve damage (common in long‑term diabetes) alters pain signalling — discomfort may appear in the jaw, neck, back, arms, or upper abdomen instead of the chest. Women are statistically more likely to present with breathlessness, fatigue, and jaw/epigastric pain than men.
Rationale: “Silent” MI is not painless — it’s differently painful. Dismissing it as indigestion or stress delays life‑saving treatment. Rule: treat any unexplained upper‑body discomfort + breathlessness + clamminess as cardiac until proven otherwise.
Guidance: NICE CG126 — Chest Pain of Recent Onset.
Question 2: Immediate Nursing Actions
What do you do right now — before the doctor arrives?
Answer:
- Bed rest — semi‑recumbent position — stop all activity to lower oxygen demand
- Oxygen only if SpO₂ <94% — avoid routine high‑flow in non‑hypoxic patients
- 12‑lead ECG within 10 minutes — the single most important early test
- Check BP → prepare GTN spray — hold if systolic <90 mmHg
- Bloods drawn — Troponin, glucose, lipids, electrolytes
- IV access established — large‑bore cannula in situ
- Stay with her — anxiety increases cardiac workload; your presence reassures
Rationale: Every minute of ischaemia damages heart muscle. The 10‑minute ECG target guides whether Primary PCI is needed. GTN drops BP — always check first.
Guidance: Resuscitation Council UK — Acute Coronary Syndrome Guidelines.
Question 3: Escalation — SBAR Handover
Call the medical team urgently. Deliver your SBAR.
Question 4: Compassion — “Don’t Make a Fuss”
Jean says, “It’s just my age, don’t make a fuss.” She’s frightened but hiding it. How do you respond?
Answer: Sit at eye level, speak calmly, validate her feelings while being gently firm:
“I understand you don’t want to worry anyone — that’s very kind of you. But these symptoms can be subtle, especially with diabetes, and we need to check them properly to keep you safe. I’m going to stay right here with you while we do the tests.”
Rationale: Women and older adults often downplay symptoms — they’ve been taught not to be “a burden.” Acknowledging that instinct builds trust. Staying beside her lowers anxiety — and anxiety raises heart rate and oxygen demand.
Further reading: British Heart Foundation — Women and Heart Disease.
🎉 You’ve Completed the Full Series!
Six essential scenarios — all evidence‑based, all ward‑ready. More coming soon.
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