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Chest Pain Evaluation
Date Start time Stop time MRN©MB and RR 2006, 2007 Revised 20Sep07
Indicates reminders for 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality MeasuresThe number following the
indicates the quality measure.
Allergies Chief complaint/Reason for consult
 Allergy List Reviewed
Medications History of present illness
Medication List Reviewed
C
hest pain rated as
1
 
2
 
3
 
4
 
5
6
 
7
 
8
 
9
10
 
Accompanying symptoms
 Nature
Sharp
Dull
Pressure
Tearing
Orthopnea or PNDDuration
(in minutes)
 
<1
1-5
6-10
11-20
21-60
>1 hour 
Dyspnea, wheezing or cough presentRadiation to
Left Arm
Right Arm
Neck
Jaw
Back
Peripheral edemaFrequency is
Stable over past 1 month
Profound fatigue
Increased in duration, nature or frequency 
Diaphoresis
Occurs or increases with exertion
Palpitations, Dizziness or Syncope
Decreases with rest
Decreased appetitePatient has received recent trauma
Yes
No
Leg pain or claudication
Recent use of medicines for erectile dysfunction
History of aortic aneurysm
(Consider aortic dissection)
 
Recent severe emesis or esophageal dilatation
Strenuous resistance exercise
(Consider aortic dissect
ion)
Social HistoryReview of Systems
Tobacco use
Packs x
Yrs
Quit
Daily, occasional and ex-smokers aremore likely to be hazardous drinkers
Alcohol use
Drinks per 
day
week
Hazardous drinking 
NIAAA (National Institute on Alcoholism and Alcohol Abuseguidelines)
 
Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day 
Recreational drug use
Inhalation
Injectable
Ingestible
Drug dependence
Narcotics
Benzodiazepines
See HPI WNL
Occupational History

 
Constitutional
Fatigue, malaise, fever/chills, weight loss, change in appetite

 
Eyes
Vision changes, New pain, Scotomas

 
ENT/mouth
Nose bleeds, dental caries, dental abscesses, jaw pain

 
Resp
Dyspnea, Cough, Phlegm, Hemoptysis, Wheeze, Witnessed Apnea
 

 
CV
Chest pain, diaphoresis, ankle edema, PND, syncope
 

 
GI
Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena

 
GU
Change in urinary habits, hematuria, dysuria

 
Musc
Myalgias, recent trauma, bony fractures, arthralgias, joint swelling
 

 
Skin/breasts
Rashes, new masses or skin lesions, increased sensitivity to sun

 
Neuro
 
Seizures, episodic or chronic muscle weakness

 
Endo
 
Hair loss, polydipsia

 
Heme/lymph
 
Bleeding gums, unusual bruising, swollen lymph nodes

 
Allergy/Immun
 
Sinus probs, recurrent infections
 

 
Psych
 
Mood changes, agitation, psychosis, delirium, dementia
Family Medical History Past Medical and Surgical History
Asthma
Congestive Heart Failure
COPD
Coronary Artery Disease
Premature Onset
Diabetes
Malignancy
Pancreatitis
Peripheral Vascular Disease
Renal Dysfunction
Thyroid Disease
Asthma
Cerebral Artery Disease
Neuromuscular weakness
Chemotherapy
Surgeries
 
Bronchiectasis
Congestive Heart Failure
Occupational exposures
Colonoscopy
COPD
Coronary Artery Disease
Pancreatitis
ECHO/Stress Test
COP (BOOP)
Diabetes
Peripheral Artery Disease
Mammogram
Cystic Fibrosis
GERD
Scleroderma
PFTs
Histiocytosis
Hepatic Dysfunction
Seizure Disorder 
PapSmear 
Tuberculosis
HIV/AIDS
Sjogren
Prior Intubations
PAH
Hypertension
Renal Dysfunction
Radiation exposure
Sarcoidosis
Inflam bowel disease
Rheumatoid arthritis
Sleep Study
Tuberculosis
Malignancy
Thrombotic Disease
Steroid use
Obstructive Sleep Apnea
Thyroid Disease
CPAP
BiPAP
 
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