Under construction
52 year-old female complaining of chest pain
Blood pressure = 138/94 Pulse = 84 Respirations = 14 Temperature = 98.2
Important features here include the onset of pain, character of the pain, severity, associated nausea, sweating, shortness of breath, radiation of the pain into the jaw or the left arm.
Thus the conversation may go as follows.
Hello Ma’am, I am Dr. Raja. And you are?
Hello. I am Angela Riley.
I was told by the nurse that you have been having chest pain. Is that correct?
Yes Doctor.
Are you still in pain?
No.
When did you first get the pain?
Yesterday doc - I woke up in the middle of the night with it.
Did you wake up because of the pain? Or did you get up for some other reasons and noticed that your chest was hurting too?
I think it woke me up.
What relieved the pain?
It just went away by itself.
How long did it last?
A few seconds or so.
Does anything provoke it now?
Not usually but when I tried to do some yard work yesterday, I felt it come back again.
How bad was the pain on a scale of 0 to 10 - zero being no pain and ten being the severest that any pain can be.
It was about a 7.
What type of pain was it?
I do not quite understand the question.
I mean to ask if it was burning or like a knife point or diffuse on the whole chest or some other character?
(If the patient says that the she is having/had sharp pain, it is important to differentiate between severe pain or knife like pain which is localized to a point. In the United States, many patients say sharp instead of severe. Another word peculiar to the US is AKS - the patient actually means ASK but pronounces it like AXE - particularly in Philadelphia.)
Burning discomfort would signify gastroesophageal reflux (heartburn). Reflux disease is worse in lying position.
Cardiac discomfort is typically diffuse, squeezing, lasts more than 30 seconds, is associated with nausea or vomiting or sweating or shortness of breath. Most patients have risk factors, which include smoking, hypertension, diabetes, positive family history & hyperlipidemia. The strongest of them are family history and smoking. Family history is considered positive if a male first-degree relative gets ischemic heart disease under the age of 55 or a female relative gets ischemic heart disease under the age of 65. Many patients say that they had people having heart disease in their families and the next question to them should be about the age of the family members at the time of onset of the ischemic heart disease.
One of the first few interventions recommended in a case like this is to provide the patient with a dose of aspirin. Immediately request an EKG stat. Place the patient on continuous cardiac monitoring, obtain IV access, request chest x-ray, examine the patient for tenderness - which is one features that most likely should be absent in the patient with cardiac disease.
One of the leading key features towards ischemic heart disease is radiation into the jaw or vomiting or sudden sweat.
Other causes to consider would-be cholecystitis, where the right upper quadrant of the abdomen would be tender particularly on deep inspiration, which is known as Murphy's sign.
Costo-chondritis also gives tenderness found on top of the ribs.
Pulmonary embolism also presents with sharp pain, which is a pleuritic in nature. One may find leg swelling associated with it and tachypnea is a prominent feature. Occasionally hemoptysis may be seen. Ventilation perfusion scan is the test of choice. Nowadays high-resolution cat scans are also good alternatives.
Pulmonary angiography is rarely done but at this stage it'll be important to review the guidelines.