Chest pain

(Redirected from 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 edit

  • name, AGE

SOAP edit

-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 edit


ROS edit

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

Impression edit

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

Differential Diagnosis edit

  • 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


Canadian Cardiovascular Society (CCS) Classification edit

  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 edit