Chest Pain – FCS

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  • \Chief Complaint: Chest Pain
  • \Hx
    • HPI
      • Onset:
        • <2 hours ago
        • 2 – 4 hours ago (estimated by pt)
        • 4-8 hours ago (estimated by pt)
        • 8 hrs to 24 hours ago (estimated by pt)
        • 1 day – 1 week (estimated by patient)
        • 1 week – 1 month
        • > 1 month
      • Duration:
        • intermittent
        • constant
      • Quality:
        • pressure
        • sharp
        • burning
      • assoc sx:
        • n/v
        • SOB
        • radiation
          • to L shoulder
          • to R shoulder
          • to both shoulders
          • to back
      • alleviation:
        • none
        • rest
      • aggravation:
        • none
        • movement
        • exertion
  • Additional Hx
    • Cardiac hx:
      • hx of cardiac risk factors:
        • known CAD,
        • HTN,
        • DM,
        • HLD,
        • tob use
        • last stress test
          • never
      • last cath:
        • never
        • \
      • illicit drug use (cocaine, methamphetamine or any other substances)
    • Pulmonary hx:
      • hx of reactive airway disease or other pulmonary disease
        • No
      • hx of DVT/PE/recent surgery/recent immobilization/estrogen use:
        • No
        • \
    • GI hx:
      • hx of GI/hepatobiliary disease:
        • no
        • worse with eating:
          • No
        • associated with abd pain/vomiting:
          • No
    • pertinent additional notes:
      • \
    • Exam: Complaint specific findings on exam:
      • CV:
        • RRR, no r/m/g
      • Pulm:
        • CBTA
        • no respiratory distress
        • rales at bases
      • LE:
        • no LE swelling
        • no unilateral swelling.
  • \ED COURSE and MDM:
    • ASA
    • received ASA >= 162 mg prehospital
    • nitroglycerin 0.4 mg SL
    • morphine
    • LABS:
      • CBC:
        • non-remarkable and non-conributatory to pt’s condition
      • BMP:
        • non-remarkable (no significant electrolyte derangement)
      • Interpretation: Basic labs normal, not suggestive of more malignant process and non-revealing of alternative malignant diagnosis causative to patient’s condition.
      • Trop:
      • Delta Trop:
      • EKG (as interpreted by prelim ED):
        • Non-remarkable EKG and no evidence of ischemia. NSR, regular rate, normal intervals, no abnormal TWI, no ST elevation/depression.
        • NSR, Non-specific repolarization abnormalities.
        • Evidence of ischemia
        • Meets STEMI criteria
        • Unchanged when compared to prior
      • CXR:
        • Normal study: no tracheal deviation, non-widened mediastenum, normal cardiac boarder, no pleural effusion, no air under diaphragm, no focal consolidation, no PTX, no gross bony abnormalities.
        • Pulmonary edema
        • Cardiomegaly
        • lobar opacity
        • (This is an ED prelim radiographic interpretation in order to increase chance of finding obvious emergent pathology which can be intervened upon and to minimize delay in care secondary to delay of radiology to be able to provide formal reads. Given these studies require board certified radiologists to review and formal reads are beyond the scope of Emergency Medicine, institutional protocol in place which will alert current care team/patient for over-reads/changes/critical reads).
  • \MDM/Ddx by system/A/P:
    • \Cardiac:
      • Considered ACS, in addition to obtaining history, inquiry into risk factors, examination, EKG, troponin, employed risk stratification pathways for ACS
        • HEART Score:
          • 0-3
            • Therefore estimated risk 0-3: 2.5% risk of adverse cardiac event. Patient’s can be discharged with followup 72 hour stress test with PMD
            • Employed HEART Pathway.
              • Pt at very low risk (HEART score <=3 and two neg trop at time 0 and 3 hr) in Heart Pathway therefore estimated >99% sensitivity for 30 day cardiac event.
            • Given above risk stratification, pt at very low risk for ACS, and while standard practice is for outpatient follow up, given varied risk tolerance of each individual patient, I discussed risks/benefits and offered prolonged observation for possible increased sensitivity, including provocative testing, and via shared decision with pt, we elected for discharge. Pt informed that they may elect to arrange prompt outpt stress test if they wish for further risk stratification. With utilization of HEART pathway, expedited arrangements by ED is not routinely indicated given above risk stratification and patient’s risk tolerance and patient encouraged to make such arrangements per their discretion of arranging outpatient follow up.
          • 4-6
            • Therefore estimated risk 20.3% risk of adverse cardiac event. Plan for admission/obs to the hospital for trending of troponin and provocative testing per inpatient .
          • >7
            • Therefore estimated risk 72.7% risk of adverse cardiac event, suggesting early invasive measures with these patients and close coordination with inpatient cardiology. Plan for admission.
      • Not consistent with aortic dissection given
        • history not consistent with dissection,
        • no widened mediastinum on chest x-ray
      • Not consistent with CHF exacerbation given
        • euvolemic on exam,
        • pulm exam/CXR not c/w pulm edema
        • no hx of CHF
      • Not consistent with pericarditis given
        • no PR depression,
        • no diffuse ST elevation,
        • no friction rub on exam
      • Not consistent with myocarditis given
        • no infectious systems,
        • no indication of decreased myocardial contractility.
    •  \Pulm:
      • Considered pulmonary embolism given my clinical gestalt is that this is not a pulmonary embolism and
        • neg PERC criteria
          • (age<50, HR<100, O2 on RA >95%, no hx of VTE, no trauma/surgery x 4wks, no hemoptysis, no exogenous estrogen, no unilateral LE swelling), therefore for being sufficiently low risk for no further indicated diagnostics
        • unlikely by Wells
          • (s/s of DVT, PE NOT #1 dx, HR<100, no immobilization x 3 days, surgery x4 wks, hx of VTE, hemoptysis, malignancy w/ tx w/in 6 mo or palliative)
          • and d-dimer neg.
        • unlikely clinically
          • given clinical criteria of no s/s of DVT, alternative diagnosis more likely, HR <100, no immbolization, no hypoxia, no hx of VTE
        • Given varied risk tolerance of patients, risks of radiation/time/contrast verses additive diagnostic benefits of further diagnostics including CTPA discussed with patient and shared decision not to pursue further diagnostics given level of risk for PE satisfactorily for patient’s wishes per my conversation with patient.
      • CTPA. Considered pulmonary embolism and given patient’s evaluation, sufficiently high for futher diagnostic pursuit that d-dimer would not provide sufficient neg post test probability. As such, CTPA performed
        • CTPA neg for PE
        • CTPA positive for PE
          • Location:
            • saddle
            • segmental
            • subsegmental
          • Hemodynamics:
            • hemodynamically stable
            • hemodynamically stable though vitals not within normal limits
            • hemodynamically unstable
      • Not consistent with pneumothorax given
        • breath sounds symmetric bilaterally,
        • no respiratory distress,
        • no pneumothorax seen on chest x-ray
      • Not consistent with pneumonia given
        • no productive cough, afebrile,
        • no respiratory distress,
        • no consolidation seen on chest x-ray.
    •  \GI:
      • Not consistent with GERD nor hepatobiliary pathology given
        • no significant assoc GI symptoms,
        • no abdominal pain in RUQ nor LUQ,
        • pain is not worse with eating
        • negative Murphy’s sign
    • chest pain, no emergent pathology elucidated on ED work up
    •  chest pain, concern for ACS
    • chest pain, concern for CHF
    • chest pain, concern for PNA
    • chest pain, secondary to PE
    • Will concurrently need ACS rule out.
    • home with prompt PMD follow up and return precautions including: worsening/persistence of chest pain/SOB/development of any new symptoms/inability to obtain advised follow up
    • home w/ booked 72 stress test
    • cardiac observation
    • admitted
  • COUNSELING: Patient/family educated on diagnostics, assessment, treatment plan. Patient/family amendable and in agreement with plan. All questions and concerns answered and addressed.
0 (slightly)
1 (mod)
2 (highly)
0 (norm)
1 (non-spec repol abnorm)
2 (sig ST-dep)
0 (<45)
1 (45-5)
2 (>=65)
RFs (HLD, HTN, DM, tob, +FH, obesity)
0 (none)
1 (1-2 RFs)
(>=3 RFs or atherosclerotic dz)
0 (<=wnl)
1 (1-2x nl)
2 (>=3 nl)
BMI= kg / (m*m), >30 -> obesity