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
