Chest pain

Physicians will typically keep asking a patient about chest pain even after they have identified it as pressure. ER Physicians need to consider whether pain is esophageal acid reflux [burning], musculoskeletal [stabbing or with movemment] or cardiac [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' 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 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 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, pulse and respiratory rate. 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

• 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?

Objective -PMHx-

• 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

Assesment

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

Other OSCE modules