Chest Pain
Distinguishing chest pain of cardiovascular origin from that occurring as a result of chest wall disorders, pleuropulmonary disorders, gastrointestinal disorders, and psychogenic states is an important training problem for medical students.
Required Skills/Procedures:
1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan
Appropriate Setting: Inpatient and Outpatient
Expected level of Responsibility: Direct supervision with real patients
Learning Topics during encounters with a patient with CHEST PAIN can include:
Medical Knowledge Learning Topics related to CHEST PAIN:
1. Common life-threatening medical causes of chest pain.
2. Signs and symptoms that:
- suggest ischemic heart disease
- are associated with chest pain due to GI disorders
- are associated with chest pain due to pulmonary disorders
- are associated with chest pain due to musculoskeletal causes
- are associated with chest pain due psychogenic causes
3. Pathophysiologic explanations of why the following factors are associated with exacerbating chest pain:
- anemia
- hypoxemia
- hypertension
- tachyarrhythmia
- hyperthyroidism
4. Identification of typical blood pressure values that occur with aortic stenosis, aortic insufficiency, and pulsus paradoxus
5. Common abnormalities that may cause paradoxical and fixed splitting of the S2 and factors that increase or diminish the intensity of S1
6. Consequences of the following risk factors and their association with heart disease:
- hypertension
- smoking
- lipid abnormalities
- age and gender
- diabetes mellitus
- family history of heart disease
- obesity
- dietary intake of saturated fat and cholesterol
- sedentary lifestyle
7. The role of critical pathway or practice guidelines in delivering high quality care for patients:
- hospitalized with ischemic chest pain
- outpatients presenting with non-ischemic chest pain
8. The use of laboratory studies in the evaluation of chest pain, including indications, limitations, and cost
9. The use of imaging studies in the evaluation of chest pain, including indications limitations, and cost
Diagnostic Evaluation Learning Topics related to CHEST PAIN:
1. Age-appropriate medical history taking, documentation, and presentation that differentiate among etiologies of disease
2. Physical examination to establish the diagnosis and severity of disease
3. Differential diagnosis generation that recognizes specific history and physical exam findings that distinguish ischemic chest pain from non-ischemic causes of chest pain (e.g., GI, pulmonary, musculoskeletal, or undetermined)
4. The use and timing of diagnostic and laboratory testing, both prior to and after initiating treatment, in consideration of the differential diagnosis, test performance, cost, and patient preferences
5. Indications for and interpretation of the significance of the results of appropriate clinical tests (with consultation as appropriate):
- echocardiogram
- exercise stress test and the use of the pretest probability of CAD to interpret results
- stress thallium (myocardial perfusion radionuclide scan)
- cardiac catheterization
- pulmonary angiography
- CT angiography
- V/Q scan
Management Plan Learning Topics related to CHEST PAIN
1. Indications, mechanism of action, side effects, adverse reactions, and significant interactions of medications that could be prescribed for patients with chest pain:
- digoxin
- calcium channel blockers
- beta blockers
- angiotensin-converting enzyme inhibitors
- nitrates
- nitroglycerin
- aspirin
- heparin
- warfarin
- clopidogrel
- thrombolytic therapy
2. Indications, benefits, and disadvantages of interventions and surgical therapy:
- PTCA
- Surgical therapy
- CABG
3. Cost and cost effectiveness of interventions, such as:
- various agents within each class of medications
- interventional strategies
- surgical approaches
4. Treatment approach for the patient with chest pain based on diagnosis, evidence about treatment options, patient characteristics, and patient preferences
5. Prognostic formulation for the patient with chest pain based on diagnosis, treatment plan, and patient characteristics
6. Communication to patients and families about the diagnosis, treatment plan, and prognosis of the disease in a caring and compassionate manner, reflecting an understanding of the emotional impact of the diagnosis and its potential effect on lifestyle (e.g., work performance, sexual functioning)
7. Patient education regarding the treatment plan
8. Patient counseling when indicated about the following issues related to prevention:
- smoking cessation
- dietary saturated fat and cholesterol reduction
- dietary sodium reduction
- weight reduction
- increased physical activity
9. Communication and patient education about primary and secondary prevention of cardiovascular disease to appropriate recipients
10. Psychological support referral, if indicated
11. Use of appropriate information systems to ascertain information about health system and community resources
12. Follow-up planning
Potential Differential Diagnosis Topics Include:
Seven common life-threatening medical causes of chest pain
- acute MI
- tension pneumothorax
- aortic dissection
- cardiac tamponade
- pulmonary embolus
- pneumonia
- ruptured esophagus
Clinical features that help to differentiate one etiology from another
- right- and left-sided congestive heart failure
- ischemic heart disease
- valvular heart disease (aortic stenosis, aortic insufficiency, mitral stenosis, mitral regurgitation)
Signs and symptoms that suggest ischemic heart disease
- angina pectoris (typical and atypical)
- Prinzmetal angina (variant angina)
- acute myocardial infarction
- unstable angina
- non-ischemic cardiovascular pain
- mitral valve prolapse
- dissecting aortic aneurysm
- pericardial pain (acute)
- cardiomyopathy
Signs and symptoms associated with chest pain due to GI disorders
- gastroesophageal reflux
- peptic ulcer disease
- biliary colic
- pancreatitis
Signs and symptoms associated with chest pain due to pulmonary disorders
- pneumonia
- spontaneous pneumothorax
- pulmonary embolism
- pulmonary hypertension
- inflammation of the pleura
Signs and symptoms associated with chest pain due to musculoskeletal causes
- costochondritis (Tietze’s syndrome)
- muscular strain
Signs and symptoms associated with chest pain due to psychogenic causes
- depression
- anxiety
- somatization
- hyperventilation syndrome
- malingering
Other
- zoster