Key Feature 4a: Given an appropriate history of chest pain suggestive of herpes zoster infection, hiatal hernia, reflux, esophageal spasm, infections, or peptic ulcer disease: Propose the diagnosis.
Skill: Clinical Reasoning Phase: Diagnosis Key Feature 4b: Given an appropriate history of chest pain suggestive of herpes zoster infection, hiatal hernia, reflux, esophageal spasm, infections, or peptic ulcer disease: Do an appropriate work-up/follow-up to confirm the suspected diagnosis. Skill: Clinical Reasoning Phase: Investigation If a patient presents with chest pain and you have considered and either ruled out or otherwise have a very low pretest probability for the 6 acutely life-threatening etiologies of the chest pain, it is then time to consider stable ischemic heart disease and the vast differential possibilities with a more detailed history and physical examination. (If not, and the patient is presenting to you in an outpatient clinic, they need an emergent referral to the nearest ED.) The illness scripts and associated work-ups/follow-ups (to ensure resolution as expected) for some of the common not acutely life-threatening and nonischemic etiologies and of chest pain are as follows (per UpToDate), with examples provided from various body systems that may be responsible. Pericarditis (Nonischemic cardiac chest pain)
Pneumonia (Respiratory system)
Esophageal or Peptic Ulcer Disease (Gastrointestinal system)
Herpes Zoster Infection
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Chest Pain Key Feature 3: In a patient with unexplained chest pain, rule out ischemic heart disease. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, Investigation Ischemic Heart Disease Key Feature 3: In a patient presenting with symptoms suggestive of ischemic heart disease but in whom the diagnosis may not be obvious, do not eliminate the diagnosis solely because of tests with limited specificity and sensitivity (ex: electrocardiography, exercise stress testing, normal enzyme results). Skill: Selectivity, Clinical Reasoning Phase: Diagnosis, Investigation Key Feature 6: In a person with diagnosed acute coronary syndrome (ex: cardiogenic shock, arrhythmia, pulmonary edema, acute myocardial infarction, unstable angina), manage the condition in an appropriate and timely manner. Skill: Selectivity Phase: Treatment In the patient who presents to clinic with a history of chest pain, the features listed below should raise your suspicion that the pain is secondary to cardiac ischemia, per UpToDate:
However well the episode(s) of chest pain fit the above descriptors, this can help you determine your pretest probability of the chest pain being secondary to cardiac ischemia. The following table suggests a way of categorizing pretest probability: If you are concerned for active cardiac ischemia and a possible myocardial infarction (MI) then you need to send any patient who comes into your outpatient office to the emergency for the appropriate workup and treatment (see last post). In the patient who presents without ongoing ischemic chest pain but in whom you suspect they may have ischemic heart disease, the next step is generally to get a baseline ECG and then refer them for cardiac stress testing. If the initial workup, either in the acute or stable patient, is negative for ischemic heart disease, be it via ECG, cardiac biomarkers, or stress testing, remember that the tests can be falsely negative. If you are still suspicious for ischemic heart disease, consider further testing with repeat ECG, repeat cardiac biomarkers, and/or coronary angiography. See the algorithm and table below for investigation and workup of suspected acute coronary syndrome. The institution at which you are working may also have a protocol for acute chest pain and suspected ACS. Consider using a Grace or TIMI score (on your medical calculator app) for risk stratification. If you think a patient may be having complications of acute coronary syndrome, see these past blog posts for management of an arrhythmia or cardiogenic shock. See this Life in the Fast Lane post about left bundle branch blocks.
Chest Pain
Key Feature 1: Given a patient with undefined chest pain, take an adequate history to make a specific diagnosis (ex: determine risk factors, whether the pain is pleuritic or sharp, pressure, etc.). Skill: Clinical Reasoning Phase: History Key Feature 2: Given a clinical scenario suggestive of life-threatening conditions (ex: pulmonary embolism, tamponade, dissection, pneumothorax), begin timely treatment (before the diagnosis is confirmed, while doing an appropriate work-up). Skill: Selectivity Phase: Diagnosis, Treatment Key Feature 5a: Given a suspected diagnosis of pulmonary embolism: Do not rule out the diagnosis solely on the basis of a test with low sensitivity and specificity. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 5b: Given a suspected diagnosis of pulmonary embolism: Begin appropriate treatment immediately. Skill: Selectivity Phase: Treatment Ischemic Heart Disease Key Feature 1: Given a specific clinical scenario in the office or emergency setting, diagnose presentations of ischemic heart disease (IHD) that are:
Phase: Hypothesis generation, Diagnosis When a patient presents with chest pain, first consider the ABCs. If the patient appears stable, the priority is then to risk stratify the likelihood of a life-threatening etiology of the chest pain, which are as follows:
If you have obtain any information via history or physical exam that raises your suspicion for any of the above, it is critical to take steps immediately to further investigate +/- intervene immediately. Information that should raise your suspicion for the above etiologies includes:
Otherwise the differential diagnosis for chest pain is broad, and includes multiple cardiac, pulmonary, gastrointestinal, musculoskeletal, psychiatric, and other causes. It is important to take a thorough history and perform a thorough physical examination of the relevant systems to narrow down the list of most likely possibilities to perform an appropriate workup. My DDx for common causes of chest pain is as follows (I keep this in the back of my mind to guide my history and physical assessment):
As you ran through the above list, you may have been thinking, "Oh, but what about this disease, and this other one, and this other one." There are a TON of possible reasons for chest pain, and the above list is simply a sample of causes for which patient may present with chest pain as their main concern. So, for example, a patient with a pneumonia may very well have chest pain as a symptom, but they are also more likely to present with shortness of breath. Hence the importance of starting with a complete history in the stable patient. Apart from the characterization of the chest pain using your go to history-taking mnemonic, it is also important to consider a patient's risk factors for cardiac other disease processes. Significant cardiac risk factors include:
When it comes to chest pain, sometimes the diagnosis is apparent based on history alone. However, more often, the history simply narrows the differential, without having the capacity to point to a specific culprit by itself. As UpToDate states, "Thoracic organs share afferent nervous system pathways. This creates significant overlap in the symptoms patients experience when thoracic organs develop disease, and makes it difficult to distinguish which organ system is involved purely on the basis of history. Patient descriptions of their symptoms can be helpful in some instances, but (...) clinicians must guard against premature diagnostic closure based upon history. Several studies demonstrate that so-called "atypical" presentations occur more often than was previously thought and misinterpretation of such presentations increases the risk for misdiagnosis and adverse outcomes." So while history is a very important component of the evaluation of the patient presenting with chest pain, keeping an initially broad differential and narrowing this down as indicated is the safest strategy. This is particularly important when it comes to the diagnosis of ischemic heart disease, be it in the emergency department or outpatient clinic setting. Myocardial infarction is a huge burden on mortality and morbidity in the population, and intervening during an acute myocardial infarction or addressing symptoms of ischemic heart disease that portend a future MI can make a huge difference on the patient's quality of life (see my next post for symptoms of stable ischemic heart disease). Unless you feel confident the patient is presenting with symptoms attributable to separate disease processes only, investigate for ischemic heart disease always. And remember, this is relevant for the atypical presentations too, in which ischemic heart disease my present as simply dyspnea, weakness, fatigue, or epigastric pain. These atypical presentations of ischemic heart disease may be more common in women, those at the extremes of age (young or elderly), patients with diabetes, and those who may have no cardiac risk factors whatsoever. Below is an approach to chest pain from UpToDate. In any patient with new ongoing chest pain, they warrant an ECG to rule out cardiac ischemia (as well as to look for clues of other etiologies that may present with ECG findings), unless the chest pain is obviously from another etiology. |
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