# Chest pain and a slow pulse in a 56-year-old: a live emergency case

> A live emergency case for medical students: a farmer at a district hospital with chest pain, faintness and a slow pulse. What to ask, red flags, the ECG first and the differential.

- Cardiology · Advanced · about 20 minutes · live emergency
- Web page: https://www.medikarya.in/case-studies/56-year-old-man-with-chest-pain-and-a-slow-pulse
- Work up this patient: https://www.medikarya.in/case-studies/56-year-old-man-with-chest-pain-and-a-slow-pulse

## How the patient presents

A farmer came to the district hospital with heavy pain in his chest for an hour and a half. He feels faint and sweaty. His son brought him on a motorbike.

## Why chest pain with a slow pulse matters

Chest pain and a slow pulse together are dangerous: the heart's rhythm may be failing because of whatever is causing the pain. You may have to stabilise him and make treatment decisions far from specialist help, so reading the pattern early is the core skill.

## What to ask in the history

- Onset, character, radiation and duration of the pain
- Sweating, nausea, vomiting, faintness, breathlessness
- Previous chest pain or heart problems
- Risk factors: smoking, diabetes, blood pressure, cholesterol, family history
- Medicines that slow the heart
- Exposure to pesticides on the farm
- Anything that would make blood-thinning or clot-dissolving drugs unsafe: recent bleeding, surgery, stroke

## Red flags

- A very slow pulse, or pauses
- Low blood pressure, faintness, confusion
- Ongoing pain
- Breathlessness or crackles in the chest
- A new murmur

## What to examine

- Airway, breathing, circulation; full observations
- Pulse rate and rhythm; blood pressure in both arms
- Jugular venous pressure, heart sounds, chest
- Signs of poor perfusion
- Pupils, sweating and secretions

## First investigations

- 12-lead ECG at once, repeated
- Continuous cardiac monitoring
- Troponin
- Potassium and other electrolytes, glucose
- Full blood count, kidney function, clotting
- Echocardiogram if available
- Cholinesterase if poisoning is a possibility and the test is available

## Differential diagnosis of chest pain with a slow pulse

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

### Heart muscle and arteries

- Acute coronary syndrome

### Conduction and rhythm

- Heart block
- Sinus bradycardia
- Drug-induced slow rhythm

### Toxic and metabolic

- Organophosphate poisoning
- High potassium
- Digoxin toxicity

### Other causes of chest pain

- Aortic dissection
- Pulmonary embolism
- Pericarditis

## Common mistakes

- Treating the slow pulse and missing what is causing it.
- Waiting for a troponin when the ECG already tells you what to do.
- Giving drugs that lower the heart rate or blood pressure further.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.