# 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

* Angina only with strenuous, rapid or prolonged activity
* 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.
* Angina with level walking at normal pace for less than 1-2 blocks, or less than 1 flight of stairs
* Inability to carry on any physical activity without developing angina