Chest pain Diagnosis and Treatment.

HPI: an in depth physical examination is essential in patients with chest pains. Sometimes the signs and symptoms of the patient will appear normal and hence the need for a thorough investigation. The subjective data to be collected include the following:Chest pain Diagnosis and Treatment.

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Onset: When did the pain begin?

Duration: is the pain chronic? How long does it last?

Characteristic: how bothersome, severe; does it affect the daily activities? Does it interfere with you night sleep?

Aggravating/Alleviating: what makes the pain more severe?

Radiation: does the pain emerge from a particular point? Is it located in a specific place or has it changed with time?

Treatments: are there any therapeutic options tried? Are they making the pain better or worse?Chest pain Diagnosis and Treatment.

REVIEW OF SYSTEMS

GENERAL: Any recent chills, cold sweats, fever, vomiting, nausea or anorexia?

HEENT:  Any neck swellings?

NEURO: is the client having dizziness, weakness, lightheadedness, or passing out?

CARDIO: are there any chest pains, inflammations on palpation?

RESP: has the client had fullness, indigestion, pressure, tightness or burning in the chest, any recent respiratory illness, and shortness of breath?

GI/GU: does the patient complain of nausea, vomiting, change in stool, constipation, dysuria, hematuria, hematochezia, and diarrhea. When is the last bowel movement?Chest pain Diagnosis and Treatment.

MSKLTL: any muscle, strain aches or fatigue?

PSYCH: Is the client anxious?

PERSONAL & FAMILY HISTORY

Any family history of respiratory chronic diseases, allergies, complications?

Any past surgeries?

SOCIAL HISTORY

Does the patient smoke or abuse alcohol and substances?

O.

Focused Physical Exam:

VITALS:  what are the client’s vital signs: RR, Ht, Wt, BMI, BP, Temp?

Thorax & Lungs: are there any adventitious sounds?

Abdomen: give a presentation of findings from auscultation, palpation, inspection and percussion of the chest and assessment of the abdomen

Skin: any changes in the moisture and color and, moisture or skin temperature

Back: observe for CVA or tenderness

Rectal Exam: examine for tenderness, pain and blood stains

Extremities: any edema, tenderness, intact distal pulses?

Neurologic: any general focal deficits?

Diagnostics: chest X-ray, blood test for measurement of enzyme levels, echocardiogram, MRI, electrocardiogram (ECG or EKG) (Hoorweg et al., 2017)Chest pain Diagnosis and Treatment.

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A.

Differential DX

• Acute chest syndrome
• Pneumonia
• Gastroesophageal reflux disease

Assessment

Acute chest syndrome

P.

Plan:

No referrals

When patients present with chest pain, especially as a constellation of symptoms, the differentials can go in several directions:
· Respiratory- embolism, pneumonia, pneumothorax, pleuritic
· Gastrointestinal-reflux, esophageal spasm, cholecystitis, pancreatitis, gastritis
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by Teresa Seright – Sunday, January 24, 2021, 7:05 AM
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· Musculoskeletal-chostrochondritis, herpes zoster
· Psychiatric-anxiety, panic disorder
· Cardiac-valve issues, infarction, pericarditis
The important thing to keep in mind with chest pain, is that the physical exam may be normal. This makes the HPI, and use of
OLD CARTS, critical to quickly determining if the presentation is emergent, urgent, or something that can be addressed in the
clinic with appropriate referrals.Chest pain Diagnosis and Treatment.
Priority Assessments
When the patient presents with chest pain, their general appearance is important. Are they pale, diaphoretic, short of breath, or
in apparent distress? Getting a set of vitals can help determine if there is tachycardia, hypotension, or hypoxia. Using a modified
OLDCARTS to quickly ascertain time of onset, location of the pain, radiation of the pain, and as best the patient can,
characteristics of the pain; temporal factors (what was the patient doing at the time); and relieving or aggravating factors (Dains,
Baumann, & Scheibel, 2016).Chest pain Diagnosis and Treatment.
Review of Systems. A focused review of systems to find out about recent illnesses, as well as cardiac, respiratory, GI and neuro
symptoms should reveal more data. In cases like this, the provider should initially assess quickly, but taking time to ask some
direct questions to quickly investigate family history and personal history focused on cardiac issues, bleeding/clotting problems
is all part of that initial assessment to determine what might be going on and in which system.
Medications and Illicit Drug Use. Is this patient on any medications that could cause prolonged QT syndrome? These might
include magnesium, quinidine, procainamide, sotalol, amiodarone, disopyramide, tricyclic antidepressants, methadone, and
phenothiazines (crediblemeds.org, 2020). If I were suspicious of this, I might ask a team member to search the Credible Meds
sight, as they generate lists of meds that are known, suspected, and conditionally associated with prolonged QT and Torsades.
You can find them at https://crediblemeds.org/
Does the patient use any illicit drugs? What has their caffeine, including energy drinks and dietary supplements been?
Do they use any herbals? Things that may seem innocuous, like green tea, can cause arrhythmias (Cohen & Ernst, 2010).Chest pain Diagnosis and Treatment. Aloe
vera can cause diarrhea and potassium depletion (2010). Ephedra for weight loss can induce a myocardial infarction (2010).
Physical Assessment. The physical assessment focus will be guided by the ROS and HPI, but certainly focus on cardiac,
respiratory, GI, brief neuro, and musculoskeletal (movement, peripheral edema)
D
Chest Tightness: Reports chest pain onset as “comes and goes”; has been occurring, “for years”; is associated with thinking
about things that upset her; and is not affected by position or activity. She denies being sick recently, other than the current
dysuria. Describes pain as tightness: “feeling like I would quit breathing” with anxiety. Denies radiation of this pain to arms, face,
or back.Chest pain Diagnosis and Treatment.
Anxiety: Feels like she is so anxious she cannot function, including going out in public. Onset-has struggled with anxiety
“forever”. However, it has gotten worse in the last 6 months.
Triggering factors include custody issues for the past few years; has not visited son in the past 3 weeks due to anxiety. Has tried
prayer; is in AA and is active with a sponsor; has stopped gabapentin (4 months ago); reports taking no medications; went
through treatment for alcohol 11 years ago.
Does not see a counselor presently, but that has helped in the past.
Dysuria: reports burning on urination for two days-drinking more water; taking azo–which helped pain. Denies hematuria.
Denies vaginal discharge. States she does have dyspareunia .
ROS:
· General- no sick contacts and denies illness recently
· Cardiac: see HPI
· Respiratory: denies cough, shortness of breath
· Neuro: Reports headaches every 2 days that she associates with stress: dull ache in temples and in neck; laying down helps;
takes ibuprofen sometimes. Denies passing out or feeling dizzy
· GI: Reports loose bowels with anxiety; poor appetite. 24 -hour recall: good breakfast two days; good supper (pasta); wants
to drink more water
· Musculoskeletal: Denies pain
Medications: denies any use of medication, herbals. Uses ibuprofen on occasion.
Past Medical History:
– Anemia
– Anxiety
– ASCUS (atypical squamous cells of undetermined significance) on Pap smear 6/15/2006
HPV +
– Benzodiazepine abuse in remission (CMS-HCC)-Court mandated treatment July 2014
– Chlamydia 7/17/2006
– Depression
– History of chicken pox
– LBP (low back pain) 10/31/2012-PT CONSULT 11/6/2012
– Molluscum contagiosum 10/30/2006-CRYO
– Narcotic abuse in remission (CMS-HCC)-Court mandated treatment July 2014 Chest pain Diagnosis and Treatment.
OB History: Gravida 2 Para 2 Term 2; menstruation onset age 13; denies dysmennorhea or PMS
Past Surgical History: none
Family History
Stroke Paternal Grandmother
Social History
– Marital status: Single- divorced Two children
– Active sexually-males
– Denies drug/ETOH use
– Smokes- 1 pack / day for 10 years
– Positive for worries about affording health care
No Known Allergies
OBJECTIVE
· Vitals BP 114/67; Pulse 98; RR 14; Sao2 97%; BMI 19.53; wt 54.9kg².
· Physical Exam
· Constitutional: Well developed, well nourished, no acute distress, non-toxic appearance
· Eyes: PERRL, conjunctiva normal.
· HENT: Atraumatic, external ears normal, nose normal, oropharynx moist, no pharyngeal exudates. Neck- normal range of
motion, no tenderness, supple. No adenopathy or thyromegaly
· Respiratory: No respiratory distress, normal breath sounds, no rales, no wheezing, no hyperventilation presently
· Cardiovascular: Normal rate, normal rhythm, no murmurs, no gallops, no rubs
· GI: Soft, nondistended, normal bowel sounds, nontender, no organomegaly, no mass, no rebound, no guarding
· GU: No costovertebral angle tenderness
· Integument: Well hydrated, no rash
· Lymphatic: No lymphadenopathy noted
· Neurologic: Alert & oriented x 3, face symmetrical, CN grossly intact by observation
· Psychiatric: Speech and behavior appropriate. Normal mood and affect Chest pain Diagnosis and Treatment.
ASSESSMENT
Problem#1: Chest tightness
Differential diagnosis:
1. Most likely diagnosis: Anxiety induced chest pain
2. Pulmonary emboli-patient is not in acute distress; vitals stable
3. Pericarditis-no history of illness; chest pain not affected by position changes
Problem#2: Anxiety
Differential diagnosis:
1. Most likely diagnosis: Generalized anxiety disorder
2. Bipolar depression –no history of, not likely
3. Endocrine issues-not likely-VS normal, no complaints of appetite issues, skin changes,
Problem#3: Dysuria
Differential diagnosis:
1. Most likely diagnosis: Urinary tract infection
2. STD
3. Vaginitis
PLAN
Problem #1: Chest Tightness
1. Testing: EKG and Troponin at bedside were normal.
CBC, CMP to assess for anemia or electrolyte abnormality that might contribute to chest tightness-all labs within normal limits.Chest pain Diagnosis and Treatment. A
TSH was drawn to assess for possible endocrine issues (hyperthyroid). The TSH was 2.3.
a. See also under anxiety-GAD-7
2. Medications: see under anxiety
3. Other therapy/consult/education: see under anxiety
4. Follow-up plan: see under anxiety
Problem #2: Anxiety
1. Testing: GAD-7 in office was 13. The GAD-7 has a sensitivity (ability to detect a problem in someone who has that problem)
of 0.83 & a specificity (ability to detect people who do not have the issue) of .84 (Plummer et al., 2016).
2. Medications:
a. propanolol 10 mg as needed for cardiac, respiratory, and GI symptoms of anxiety up to three times daily- not to exceed 30
mg. Drink plenty of fluids. Avoid sudden position changes. This is actually not best practice—and something I would not have
prescribed, were I the provider (Steenen et al., 2016). I believe sometimes providers feel compelled to order something that the
patient can feel immediately. Instead, I would use education and reinforcement that counseling and an SSRI will take time to
work. In the meantime, the patient can investigate apps for deep breathing and relaxation; engage in better daily habits, like a
daily walk, and generally tune in to what would be healthy and beneficial alternatives to ruminating.Chest pain Diagnosis and Treatment.
b. citalopram 20 mg daily by mouth. If feeling sleepy, may take at bedtime instead of in the morning.
3. Ambulatory referral to counseling at (this site)
a. Counseling and an SSRI are co-first line treatment recommendations and have been found to be equally efficacious (Carl et
al., 2019).
4. follow up in 3 weeks to evaluate effectiveness of dose of citalopram and effect of propranolol (which again, I would
discontinue).
Problem #3: Dysuria
1. Testing: urinalysis culture (dipstick showed + protein, leuk, blood; UA confirmed that). Will follow up with patient for results.
Pyuria is present in most patients who later have a confirmed UTI (Hooten & Gupta, 2020).
2. Medications:
a. Macrobid 100 mg BID x 5 days. Nitrofurantoin is a first line recommendation for an uncomplicated UTI;
Sulfamethoxazole/trimethoprim is an alternative option (
3. Counseling: drink plenty of fluids; may take ibuprofen for discomort; report to clinic or ER if you develop a fever, chills,
backpain, or if symptoms continue beyond antibiotic doses. Take all of the macrobid—even if feeling better.
4. Follow up: as needed-see “counseling” above.Chest pain Diagnosis and Treatment.