Chest Pain Examination

CHEST PAIN: ISCHEMIC HEART DISEASE

Chest Pain Differential Diagnosis:

What you should be thinking when asking questions and doing a physical examination on a patient with chest pain.

CARDIAC

Angina: Stable vs. Unstable
Acute myocardial infarction.
Pericarditis
Myocarditis
Dissecting aortic aneurysm

PULMONARY

Pneumonia
Pneumonia with pleuritis
Pneumothorax
Pulmonary embolism
Pulmonary hypertension (e.g. COPD, CHF)

GI

GERD, gastric reflux
Esophageal spasm
Peptic ulcer disease

MSK

Arthritis
Chondritis
Rib fracture

PSYCHIATRIC

Anxiety
Panic attack

Chest Pain History:

Identifying Data

Chief Complaint

History of Present Illness
OPPQRS…

- CHEST PAIN
- onset and duration, past occurrences
- point to the pain
- what provoked the pain, worse with exertion, rest, stress
- quality of the pain
- quantify the pain
- radiation
- severity
- timing – at rest, exertion
- u – happened before
- v – what alleviates the symptoms
- w – what do you think is wrong
- x –all treatments, doctors seen, investigations done in past

Review of Systems:

- General: nausea, vomiting, sweats, etc...
- Head and Neck
- Cardiac
- Respiratory
- Neurological

Important associated symptoms:

dyspnea, shortness of breath, cough, palpitations, ankle edema, leg pain, hemoptysis, fever

Past Medical History

Risk Factors

Know heart disease, diabetes, high cholesterol, high blood pressure, smoking, family history of heart disease or stroke or high blood pressure or diabetes

Medications and Allergies

Social History

Chest Pain Physical Examination

Vitals

Precordial examination

Chest, pulmonary, examination

Appearance of patient: Distress, Cyanosis, Clubbing, Pallour
Scars, previous surgeries
Bony abnormalities
Signs of inflammation, chondritis
Visible impulses
Point of maximum impulse: location, size, shape, duration of impulse
Heaves, lifts, thrills
Auscultation in the four zones of the heart to listen for disease, valvular
Supine: S1, S2 diaphragm and bell
Upright: S1, S2 diaphragm and bell
Left lateral decubitus: S3, S4 only at apex with BELL only
Lean forward: diastolic murmurs, base of heart with BELL

INVESTIGATIONS/LABS:

- LABS: CBC, Lytes, TSH, Fasting Lipids, Fasting blood glucose
- CXR (baseline)
- ECG: Know Rate, Rhythym, Axis, Ischemia (ST segment elevation)., infarction, blocks
- HOLTER (Ambulatory ECG)
- STRESS TESTING
- ECHO: 2D vs. Transesophageal
- CORONARY ANGIOGRAPHY: Gold standard for detecting CAD

MANAGEMENT:

ACUTE CORONARY SYNDROMES (AMI, Unstable Angina)

- MEDICAL
- B-BLOCKER (1st line)Side-effects: Fatigue, Bradycardia, Dizziness, Impotence
- ECASA (to everyone)  Side-effects: GI upset, PUD, N+V, Tinnitus, Vertigo, Anaphylaxis, Bleeds
- NITRATES (symptomatic)  Side-effects: Headache, Dizziness, Postural Hypotension
- CCBs (2nd line)
* TREAT RISK FACTORS: Lipids, Hxn, Diabetes Mgt, Smoking, Wt. Loss, Exercise...
- SURGICAL
- PTCA (Percutaneous Transluminal Coronary Angioplasty)
- CABG (Coronary Artery By-Pass Graft)