Approach to Chest Pain

1. Approach to Chest Pain
Intern Bootcamp, 2014
Nathan Stehouwer, MD
PGY-4, Internal Medicine & Pediatrics

2. Differential

4. Pearl: ALWAYS have the patient
point to the pain!

5. Typical vs. Atypical Chest Pain
Typical
 Characterized as
discomfort/pressure rather than
pain
 Time duration >2 mins
 Provoked by activity/exercise
 Radiation (i.e. arms, jaw)
 Does not change with
respiration/position
 Associated with
diaphoresis/nausea
 Relieved by rest/nitroglycerin
Atypical
 Pain that can be localized with
one finger
 Constant pain lasting for days
 Fleeting pains lasting for a few
seconds
 Pain reproduced by
movement/palpation

6. Typical vs. Atypical Chest Pain
UpToDate

7. Typical vs. Atypical Chest Pain
Cayley 2005

8. Case 1
 You are the orphan intern on Wearn team at 6PM. You
are called by the nurse because Ms. Z has developed
chest pain. Ms. Z is a 62 yo F with PMHx of CAD s/p
remote PCI to the LAD, COPD and right THA 3 weeks
ago who was admitted for a COPD exacerbation.
 What would you do next?

9. Evaluation of Chest Pain
Case 1:
 Ask nurse for most current set of vital signs
 Ask nurse to get an EKG
 Obtain the admission EKG from the paper chart
 Go see the patient!

10. Evaluation of Chest Pain
 Once at bedside, determine if patient is stable or unstable
 Perform focused history and physical exam
 Read and interpret the EKG. Compare EKG to old EKG if
available
 If patient looks unstable or has concerning EKG findings, call
your senior resident for help
 Write a clinical event note!

11. Evaluation of Chest Pain
focused physical exam for chest pain
 Vital Signs: tachycardia, hypertension/hypotension or hypoxia
 General: Sick appearing, actively having chest pain
 HEENT: JVD, carotid bruits
 Chest: Rales, wheezes or decreased breath sounds
 CVS: New murmurs, reproducible chest pain, s3 gallop
 Abd: Abdominal tenderness, pulsatile mass
 Ext: Edema, peripheral pulses
 Skin: Rash on chest wall

12. Case 1
 You go see the patient. She had been feeling better after getting
duonebs, but suddenly developed chest pain that is L-sided, 8/10
and worse with breathing. This pain is not like her prior MI.
 Vital signs: Afebrile, HR 120, BP 110/70, RR 28, O2 sat 89% on 2L
(was 95% on RA this morning)
 Physical exam
 Gen – in distress, using accessory muscles of respiration
 Lungs – CTAB, no rales/wheezes
 Heart – tachycardic, nl s1, loud s2, no mumurs
 Abd – soft, NT/ND, active BS
 Ext – b/l LEs warm and well perfused
 Labs:
 CBC wnl, RFP wnl, BNP = 520, D-dimer = positive, Troponin = 0.12

13. Case 1

14. Case 1

15. Differential

16. Modified Wells Criteria
 Clinical symptoms of DVT (3 points)
 Other diagnoses less likely than PE (1 point)
 Heart Rate >100 (1.5 points)
 Immobilization >/= 3 days or surgery within 4 weeks (1.5 points)
 Previous DVT/PE (1.5 points)
 Hemoptysis (1 point)
 Malignancy (1 point)
 Interpretation:
 >6: high
 2-6: moderate
 <2: low

17. Next moves
 DDIMER: 95% sensitive, VERY nonspecific
 ABG – Elevated A-a gradient fairly sensitive, highly
nonspecific
 EKG – most commonly nonspecific changes (ST/T wave
changes, etc)
 V/Q scan – helpful in patients with HIGH or LOW pretest
probabilities in whom a CTPE cannot be obtained (eg CKD)
 LE Ultrasound: not sensitive
 CTPE
 Sensitivity 83%
 Specificity 96%
 Moderate - high clinical probability and positive CTPE: 92-96%
chance of PE

18. Pearl
A CT angiogram (important for evaluating for Pulmonary
Embolism or Aortic Dissection) requires EITHER:
1) At least a 20G peripheral IV
OR
2) A Power injectable central line

19. Case 1

20. Continue reading…
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