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Approach to chest pain

  • Take a focused history: Ask about the character and quality of pain, provoking and relieving factors, duration and frequency.

  • Perform a targeted exam: Vitals (including BP in both arms and legs), cardiac and chest wall exam, pulmonary exam, abdominal exam.

  • Differential diagnosis:

    • - Think about the five “cannot-miss” causes of chest pain: 1) ACS; 2) PE; 3) Aortic dissection; 4) Tension pneumothorax; 5) Esophageal rupture.

    • - Then can consider a broader differential diagnosis by organ system (Table 1.5)

  • Initial diagnostics:

    • - ECG: Look for ST changes (ACS, pericarditis, demand), RV strain (PE), Q waves (evidence of prior ischemia)

    • - CXR: Look for pneumonia, rib fractures, pneumothorax, widened mediastinum (can occur due to aortic dissection)

    • - D-dimer: Use age-adjusted cutoff for patients >50 yr (age × 10 = upper limit cutoff); normal d-dimer can:

      • Rule out PE in low to intermediate clinical probability situations

      • Rule out aortic dissection in low risk patients (i.e., no connective tissue disease; no new murmur; no chest, abdominal, or back pain that is abrupt, severe, or ripping)

  • CT scan: Timing of contrast differs slightly depending on whether the imaging focuses on the systemic or pulmonary arteries

    • - CTA (CT angiography with arterial contrast) is used if most concerned for aortic dissection

    • - CTPA (CT pulmonary angiography) is used if most concerned for PE

TABLE 1.5Etiologies of Chest Pain by System

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