Chest pain

Physicians will typically keep asking a patient about chest pain even after they have identified it as pressure. Emergency Room Physicians need to consider whether pain is esophageal acid reflux [burning], musculoskeletal pain[stabbing or with movemment] or cardiac pain [at rest or exertional], the latter requiring a 'chest pain protocol' evaluating cardiac enzymes creatine kinase and toponin and ending with a stress test or cardiac catheterization in the hospital. It may help for the evaluator to write out 'chest pain' or 'chest pressure'[feeling of ‘heaviness of chest’]and refer back to this to expedite the interview. Associated symptoms are pain in the neck, jaws, shoulders, arms or hands; breathlessness [dyspnea], inappropriate sweating, nausea, or exertional dizziness or physical exhaustion. It is important to memorize this list so that you can say you have reviewed a complete set with the patient. Diabetes reduces or obliterates symptoms of myocardial ischaemia and infarction because of autonomic neuropathy. Associated physical signs of an impending heart attack [angina, ischemia] or heart attack [myocardial infarction] are high or low blood pressure,increased pulse rate[tachycardia) and respiratory rate[tachypnoea]. Dyspnea and/or Pain on inspiration [pleurisy] should be evaluated by computed tomography for pulmonary embolus, another fatal treatable process.

ID

 * name, AGE

SOAP
-HPI- Subjective Objective -PMHx-
 * O = onset
 * Sudden or gradual onset?
 * P = precipitating
 * What were you doing when pain came on?
 * palliation
 * NO, antacids, rest, positional
 * provocative
 * exercise, food,  emotion, deep breaths
 * Q = quality
 * sharp, dull, heavy, squeezing, tearing
 * R = radiation
 * Point to where pain is and goes. (neck, jaw)
 * S = symptoms, severity
 * sweating, SOB, palpitations, cough, syncope/presyncope, anxiety, sour-taste, nausea
 * T = timing
 * Describe the course of the pain. (worsening, intermittent, better)
 * Timing of day.
 * V = déjà vu
 * Have you felt similar symptoms before?


 * Previous similar episodes? (past therapy, investigations)


 * Hx: MI, documented CAD, angioplasty, CABG
 * Important historical risk factors
 * Smoking
 * Hypertension
 * Diabetes mellitus
 * hypercholesterolemia
 * positive family history

Medication/allergies
Assessment

ROS

 * syncope, exercise intolerance, PND/orthopnea, angina, CVA

Impression

 * Is the chest pain typical or atypical for angina?
 * look at the ECG, cardiac enzymes, CXR

Differential Diagnosis

 * CV: stable or unstable angina (< 10 min, worsened by cold air, stress)
 * IHD (> 30 min, unrelieved)
 * aortic dissection
 * pericarditis (hrs to days, relieved by sitting up and leaning forward)


 * RESP: pneumothorax, PE, pleuritis
 * GI: GERD, PUD, esophageal spasm
 * MSK: costochondritis, rib fracture
 * MISC: panic attack, herpes zoster

Plan

Canadian Cardiovascular Society (CCS) Classification

 * 1) Angina only with strenuous, rapid or prolonged activity
 * 2) Angina only slightly limiting ordinary activity, such as walking up-hill, climbing stairs rapidly, or climbing more than 2 blocks on the level, at a normal pace.
 * 3) Angina with level walking at normal pace for less than 1-2 blocks, or less than 1 flight of stairs
 * 4) Inability to carry on any physical activity without developing angina