Is patient downplaying symptoms? Identify MI

While observing an elderly woman rubbing her arm as though it was a muscle ache, which she said was from gardening work, the possibility of a heart attack didn't cross the mind of the ED nurse caring for the patient. "She was so nonchalant about it," says Bridget Joyce, RN, BSN, CEN, chest pain coordinator/stroke coordinator at Our Lady of the Resurrection Medical Center in Chicago.

Because of the patient's age, an EKG was ordered, which showed an ST-elevation myocardial infarction (STEMI). "Your heart sinks when you are performing an EKG and STEMI is printing out, especially when you know you should have recognized those symptoms in a woman," says Joyce.

In Joyce's first year as an ED nurse, a young man with normal vital signs told her that he'd eaten some spicy food and had heartburn. "I sent him back to the waiting room, not thinking that this may be a life-threatening emergency," she says. "When staff brought the patient back, after a '[gastrointestinal] cocktail' not working, an EKG was performed, showing STEMI."

Use critical thinking skills even if a patient downplays his or her symptoms, says Joyce. "You have to think the worst. The patient needs you to be looking out for their best interest and safety," she says.

Ask these questions

Your patient may be anxious over having a cardiac event because of family history or sometimes even their own guilt, says Joyce. "They may think that the lifestyle they have been living caused this event to occur," she says. "Assure them that there are resources to help them if they want to change their lifestyle." To improve your assessment, Joyce gives these tips:

If a patient doesn't answer a question correctly, don't get upset with him or her.

"It is easy to get frustrated when you are busy and bouncing from patient to patient," says Joyce. "It is in the best interest of the patient to find out the most accurate history."

Rephrase the question, or ask a different question that may ultimately give you the information you're looking for, she says.

Focus on the patient when you are asking questions.

You may be placing the patient on a monitor, drawing blood, and performing an EKG, but it's important to look your patient in the eye, says Joyce.

"Give them a minute of your time," she advises. "This will gain a patient's trust, and allow them to feel comfortable telling you their information."


For more information on assessment of myocardial infarction, contact:

  • Bridget Joyce, RN, BSN, CEN, Chest Pain Coordinator/Stroke Coordinator, Our Lady of the Resurrection Medical Center, Chicago. Phone: (773) 527-5069. E-mail:

Clinical Tip

Get specifics from patient about pain

Your patient may not necessarily give you the answer "10 out of 10," even if the chest discomfort they are experiencing is the worst pain they've ever had, warns Bridget Joyce, RN, BSN, CEN, chest pain coordinator/stroke coordinator at Our Lady of the Resurrection Medical Center in Chicago. "More often than not, the pain scale is a very subjective question to ask," she says.

Jones says to ask the patient-specific questions such as "Does the pain radiate anywhere?" or "Does it go down your arm, to your back, or up to your jaw?"

"Have them characterize their pain as crushing, dull, stabbing, or heaviness," she adds.