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

• 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

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