On Call: Chest Pain

Differential Diagnosis

Primary Concerns (Immediate Threat to Life)

  • Myocardial Infarction (MI)
  • Pulmonary Embolism (PE)
  • Aortic Dissection
  • Tension Pneumothorax
  • Pericardial Tamponade

Secondary Concerns

  • Musculoskeletal:
    • Costochondritis
    • Trauma/Rib Fracture
    • Postoperative Pain
  • Cardiac:
    • Pericarditis
    • Congestive Heart Failure
  • Pulmonary:
    • Pneumonia
    • Pleural Effusion
  • GI:
    • Esophageal Reflux
    • Esophagitis
    • Peptic Ulcer Disease
    • Symptomatic Cholelithiasis
    • Cholecystitis

Particular Concerns for History & Physical

Vitals

  • ABC’s – Airway, Breathing & Circulation
  • Vital Signs

Subjective

  • Description of Pain (O-P-Q-R-S-T)
    • Onset
    • Provoking Factors
    • Quality (Pressure, Sharp, Pleuritic)
    • Radiation (Shoulder, Jaw, Back)
    • Site of Pain
    • Timing (Constant, Intermittent)
  • Shortness of Breath
  • Associated Factors

History

  • History of Cardiac Disease
  • History of Reflux
  • Surgical History

Physical Exam

  • Chest Rise
  • Heart/Lung Auscultation
  • Jugular Venous Distention
  • Abdominal Pain
  • Abdominal Distention

Work Up & Management

Initial Orders

  • EKG
  • Chest X-Ray
  • Troponin

Other Potential Orders

  • Arterial Blood Gas (ABG)
  • Other Labs (CBC, CMP, BNP)
  • CT Chest
  • CT Abdomen/Pelvis
  • CTA Chest
  • CT Pulmonary Angiogram

Further Management