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CHEST PAIN

Chief Compliant: The patient is a 50


year old white male with
hypertension who complains of chest
pain for 4 hours.

What do you want to ask


the patient?

History of the present illness:


1/
2/
3/
4/
5/
6/

Duration of chest pain.


Location, radiation (to arm, jaw, back),
Character (squeezing, sharp, dull)
Intensity
Rate of onset (gradual or sudden)
Relationship of pain to activity (at rest, during
sleep, during exercise)
7/ Relief by nitroglycerine;
increase in frequency or severity of baseline
anginal pattern. Improvement or worsening of pain.
8/ Associated Symptoms: Diaphoresis, nausea,
vomiting, dyspnea, orthopnea, edema, palpitations,
syncope, dysphagia, cough, sputum, paresthesias.
9/ Past episodes of chest pain. Age of onset of angina.

Cardiac Testing: Past stress testing, stress


echocardiogram, angiogram, ECGs.
Cardiac Risk factors: Hypertension,
hyperlipidemia, diabetes, smoking, and a
strong family history (coronary artery disease
in early or mid-adulthood in a first-degree
relative).
PMH: History of diabetes, claudication, stroke.
Exercise tolerance; history of peptic ulcer
disease. Prior history of myocardial infarction,
coronary bypass grafting or angioplasty.
Social History: Smoking, alcohol, cocaine
usage,
Medications: Aspirin, beta-blockers, estrogen.

After asking history, what


do you do next?

2/ Physical examination:

General:
Vital sign:
Skin:
HEENT:
Chest
Heart:
Abdomen:
Rectal:
Extremities:
Neurologic

General: Visible pain, apprehension, distress, pallor. Note


whether the patient appears ill, well, or malnourished.
Vital Signs: Pulse (tachycardia or bradycardia), BP (hypertension
or hypotension), respirations (tachypnea), temperature.
Skin: Cold extremities (peripheral vascular disease), xanthomas
(hypercholesterolemia).
HEENT: Fundi, silver wire arteries, arteriolar narrowing, A-V
nicking, hypertensive retinopathy; carotid bruits, jugulovenous
distention.
Chest: Inspiratory crackles (heart failure), percussion note.
Heart: Decreased intensity of first heart sound (S1) (LV
dysfunction); third heart sound (S3 gallop) (heart failure,
dilation), S4 gallop (more audible in the left lateral position;
decreased LV compliance due to ischemia); systolic mitral
insufficiency murmur (papillary muscle dysfunction), cardiac rub
(pericarditis).
Abdomen: Hepatojugular reflux, epigastric tenderness,
hepatomegaly, pulsatile mass (aortic aneurysm).
Rectal: Occult blood.
Extremities: Edema (heart failure), femoral bruits, unequal or
diminished pulses (aortic dissection);calf pain, swelling
(thrombosis).
Neurologic: Altered mental status.

3/ Lab test

ECG
Chest X-ray
CMC
Troponin I or troponinT
Myoblobin, ADH,.

IN short,
Taking a careful history
Physical examination
Lab tests