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Chest Pain Evaluation

Chest Pain Evaluation

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Published by e-MedTools
The chest pain evaluation MedicalTemplate is suitable for any health care provider that manages patients with chest pain in inpatient and ambulatory settings.

The American Heart Association reports that 8.9 Million people experience angina (cardiac chest pain) each year, and that 400,000 new cases of angina are diagnosed each year. Angina is the most common symptom of heart disease, which is the leading cause of death for men and women in the United States. The CDC reports that 29% of the deaths in 2002 (the most recent year with published statistics) were due to heart disease. More women than men died of heart disease in 2002.

Because of the prevalence and significance of cardiac related chest pain, a comprehensive cardiac evaluation forms the cornerstone of any chest pain evaluation. However, other causes of chest pain such as pulmonary embolisim, pneumonia, pericarditis, esophagitis, and aortic dissection must also be considered.
The chest pain evaluation MedicalTemplate is suitable for any health care provider that manages patients with chest pain in inpatient and ambulatory settings.

The American Heart Association reports that 8.9 Million people experience angina (cardiac chest pain) each year, and that 400,000 new cases of angina are diagnosed each year. Angina is the most common symptom of heart disease, which is the leading cause of death for men and women in the United States. The CDC reports that 29% of the deaths in 2002 (the most recent year with published statistics) were due to heart disease. More women than men died of heart disease in 2002.

Because of the prevalence and significance of cardiac related chest pain, a comprehensive cardiac evaluation forms the cornerstone of any chest pain evaluation. However, other causes of chest pain such as pulmonary embolisim, pneumonia, pericarditis, esophagitis, and aortic dissection must also be considered.

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Published by: e-MedTools on Sep 08, 2008
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09/06/2012

Chest Pain Evaluation

Allergies

Date

Start time

Stop time

MRN

Chief complaint/Reason for consult

‰Allergy List Reviewed
Medications History of present illness

‰Medication List Reviewed

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Chest pain rated as ‰1 ‰2 ‰3 ‰4 ‰5 ‰6 ‰7 ‰8 ‰9 ‰10
Nature ‰Sharp ‰Dull ‰Pressure ‰Tearing Duration (in minutes) ‰<1 ‰1-5 ‰6-10 ‰11-20 ‰21-60 ‰>1 hour Radiation to ‰Left Arm ‰Right Arm ‰Neck ‰Jaw ‰Back Frequency is ‰Stable over past 1 month www.e-medtools.com ‰Increased in duration, nature or frequency ‰Occurs or increases with exertion ‰Decreases with rest Patient has received recent trauma ‰Yes ‰No

Accompanying symptoms

‰Orthopnea or PND ‰Dyspnea, wheezing or cough present ‰Peripheral edema ‰Profound fatigue ‰Diaphoresis ‰Palpitations, Dizziness or Syncope ‰Decreased appetite ‰Leg pain or claudication

‰Recent use of medicines for erectile dysfunction ‰History of aortic aneurysm (Consider aortic dissection) ‰Recent severe emesis or www.e-medtools.com Strenuous resistance exercise (Consider aortic dissection) esophageal dilatation ‰
Social History
‰Tobacco use

Review of Systems
See HPI WNL

‰Packs x ‰Yrs ‰Quit
‰ Alcohol use Hazardous drinking

Occupational History
Constitutional Fatigue, malaise, fever/chills, weight loss, change in appetite www.e-medtools.com 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 www.e-medtools.com 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

Daily, occasional and ex-smokers are more likely to be hazardous drinkers

‰Drinks per ‰day ‰week
NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines)

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

‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰

Family Medical History
‰ Asthma ‰ Congestive Heart Failure ‰ COPD ‰ Coronary Artery Disease ‰ Premature Onset ‰ Diabetes ‰ Malignancy ‰ Pancreatitis ‰ Peripheral Vascular Disease ‰ Renal Dysfunction ‰ Thyroid Disease

Past Medical and Surgical History
‰ Asthma ‰ Cerebral Artery Disease ‰ Bronchiectasis ‰ Congestive Heart Failure ‰ COPD ‰ Coronary Artery Disease ‰ COP (BOOP) ‰ Diabetes ‰ Cystic Fibrosis ‰ GERD ‰ Histiocytosis ‰ Hepatic Dysfunction ‰ Tuberculosis ‰ HIV/AIDS ‰ PAH ‰ Hypertension ‰ Sarcoidosis ‰ Inflam bowel disease ‰ Tuberculosis ‰ Malignancy ‰ Obstructive Sleep Apnea ‰ CPAP ‰ BiPAP ‰ Neuromuscular weakness ‰ Occupational exposures ‰ Pancreatitis ‰ Peripheral Artery Disease ‰ Scleroderma ‰ Seizure Disorder ‰ Sjogren ‰ Renal Dysfunction ‰ Rheumatoid arthritis ‰ Thrombotic Disease ‰ Thyroid Disease ‰ Chemotherapy Surgeries ‰ Colonoscopy ‰ ECHO/Stress Test ‰ Mammogram ‰ PFTs ‰ PapSmear ‰ Prior Intubations ‰ Radiation exposure ‰ Sleep Study ‰ Steroid use

œIndicates reminders for 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures The number following the œ indicates the quality measure.

©MB and RR 2006, 2007

Revised 20Sep07

Chest Pain Evaluation
Vitals
Weight BMI Temperature BP Sitting Lying Standing Pulse Respiratory Rate Sats

Date Exam Const Eye

Start time

Stop time

MRN

‰Checked box indicates findings are within normal limits

‰General + 3 vital signs ‰Conjunctivae ‰Pupils ‰Discs ENT ‰TM ‰Pharynx ‰Dentition ‰Nasal ‰External ears ‰Hearing Neck ‰Exam ‰Thyroid ‰Jugular venous distention absent www.e-medtools.com Resp ‰Auscultation ‰Effort CV ‰Ausc ‰Palp ‰Edema ‰Carotids ‰Abdominal Aorta ‰Femoral pulses ‰ Pedal pulses + 2 BPs GI ‰Abdomen ‰No hepatosplenomegaly ‰No hernias ‰Rectum ‰Guaiac Lymph ‰Neck ‰Axilla ‰Groin ‰Other www.e-medtools.com Musc ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength Skin ‰Inspection ‰Palpation Neuro ‰CN ‰DTR ‰Sensation Psych ‰Affect ‰Orientation ‰Insight ‰ Memory
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Impression and Plan Increased risk factors

Labs/Tests

‰CXR (PA & lateral) ‰CT of chest

‰12 lead ECG ‰ECHO ‰Cardiac Enzymes ‰Troponin ‰Lipid panel ‰BNP ‰TSH ‰D-dimer ‰CBC ‰CMP ‰Hgb A1C ‰CRP ‰Urine toxicology
Interventions

(PE protocol if PE suspected)

‰Elevated troponin ‰High risk stress test www.e-medtools.com ‰ECHO with EF of </= 0.4 ‰MI in past 6 months ‰Prior CABG ‰Hemodynamic instability ‰Ventricular tachycardia www.e-medtools.com ‰ST segment depression (ECG) ‰Resting pain >20 minutes ‰Age > 65 years
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‰Beta-blocker ‰ACE Inhibitor ‰Statin ‰Antiplatelet agent ‰Nitrates ‰Morphine ‰Heparin or LMWH ‰Cardiac diet ‰Smoking cessation counseling

Signature

CODE STATUS ‰Patient is a FULL CODE ‰DNAR DO NOT ATTEMPT RESUSCITATION ‰ Patient has completed advanced health care directivesœ47 HCPOA is

Data Reviewed Coordination of care

‰ER Notes ‰Old Chart ‰Nursing Notes & Vitals log ‰Labs ‰Radiology data ‰ECHO ‰ECG ‰Stress Test ‰PFT ‰Diabetic log ‰ED MD ‰HCPOA ‰PCP ‰Case Mgmt ‰SW ‰Pharmacy ‰Nutrition team ‰Physical therapy ‰Respiratory therapy ‰Nursing
©MB and RR 2006, 2007 Revised 20Sep07

œIndicates reminders for 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures The number following the œ indicates the quality measure.

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