Hx
     Location
     Quality
     Severity
     Radiation
     Duration
     Context (exertional, postprandial, positional, cocaine use, trauma)
     Associated symptoms
          Sweating
          Nausea
          Dyspnea
          Palpitation
          Sense of impending doom
     Exacerbating and alleviating factors (esp. medications)
     Prior hx of similar sx
     Known heart or lung disease
     History of diagnostic testing
     Cardiac risk factors
          HTN
          Smoking
          Family history of early MI
     Pulmonary emolism risk factors
          Hx of DVT
          Coagulopathy
          Malignancy
          Recent immobilization

PE
     Vital signs incl. BP in both arms
     Complete CV exam
          JVD
          PMI
          Chest wall tenderness
          Heart sounds
          Pulses
          Edema
     Lung exam
     Abdominal exam

Ddx

Chest Wall Pain	Pleuritic Pain	Visceral Pain
Costosternal syndrome	PE	Typical exertional angina
Costochondritis	Pneumonia	Atypical (nonexertional) angina
Precordial catch syndrome	Spontaneous pneumothorax	Unstable angina
Slipping rib syndrome	Pericarditis	Acute myocardial infarction
Xiphodynia	Pleurisy	Aortic dissection
Radicular syndromes		Pericarditis
Intercostal nerve syndromes		Esophageal reflux or spasm
Fibromyalgia		Esophageal rupture
		Mitral valve prolapse

     Myocardial infarction
     GERD
     Angina
     Costochondritis
     Sickle cell disease-pulmonary infarction
     Aortic dissection
     Pericarditis
     Pulmonary embolism
     Pneumothorax
     Pneumonia
     Pancreatitis
     Fat embolism
     Esophagitis
     Peptic ulcer disease
     Esophageal spasm
     Esophageal rupture

Workup, phone orders
     Oxygen
     EKG
     Portable CXR
     ABG
     Labs: CBC, BMP, iCa, Mg, Phos, Enzymes, Coags

Workup (general)
     EKG--acute myocardial ischmia, infarction, pericarditis and tamponade have characteristic changes on EKG
     Cardiac enzymes (CK, CK-MB, troponin)--specific tests for myocardial tissue necrosis
     CXR--wide mediastinum suggests aortic dissection and may reveal other causes of chest pain, including pneumothorax and pneumonia
     TTE--can demonstrate segmental wall motion abnormalities in suspected acute MIs (infarction is unlikely in absence of wall motion abnormalities)
     TEE--highly specific and sensitive for aortic dissection, and can be done rapidly at the bedside
     CT-chest with IV contrast--another rapidly available diagnostic study that can rule out aortic dissection or pulmonary embolism
     Upper endoscopy--can document tissue damage characteristic of GERD. However, may be normal in up to 1/2 of symptomatic patients; esophageal probe (pH and manometry measurements) together with endoscopic visualization constitutes an effective diagnostic technique
     Cholesterol panel--can identify a critical risk factor for cardiovascular disease

Content on this page has not been checked for accuracy. The author's credentials have not been confirmed. Always use multiple peer-reviewed scholarly sources and good clinical judgement in your decision making.

The Compendium platform was created by David Kwinter, MD, CCFP(EM).

Dr. Kwinter is a Cayman Family Doctor. He runs a Family Medicine Clinic at Cayman Medical in George Town, Grand Cayman, Cayman Islands.