Chest Pain
Age: years old
Gender:
HISTORY:
Presents with a - history of chest pain
Onset was , started ,
Location is
Radiation to
Rated at / 10
Described as
Pattern
Episodes last for , recur times per
Worsening factors: , ,
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
, /IV
,
, episodes , ,
, up to °, over
, of phlegm
Cardiovascular risk factors:
Pulmonary embolism risk factors:
Other factors:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: acute coronary syndrome, myocardial infarction, angina pectoris, atypical chest pain, pericarditis, musculoskeletal pain, costochondritis, GERD, pulmonary embolism, aortic dissection, pneumothorax, esophageal spasm, esophageal rupture, pneumonia, rib fracture, anxiety/panic disorder, herpes zoster, gallbladder disease, peptic ulcer disease
PLAN:
Investigations:
- ECG
- Chest X-ray
- Blood work: , , , , , , , , ,
- Stress test
- CT angio of the chest
- Cardiac catheterization
Treatments:
- Aspirin 80mg 4 tablets po STAT then 1 tablet daily
- Nitroglycerin 0.4mg sublingual q 5 min up to 3 doses
-
Further care:
- Referral to cardiologist
- Referral to ER
- Follow up if not better or worsen
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: