The Cardiac assessment:
Much like the complaint of dyspnea must be considered with a systems based approach, we need to consider the potential cardiac patient through that same lens. The systems if the body do not exist in isolation; everything is interconnected. Just like dominoes, when one falls, there is a chain reaction felt throughout the body. When considering a patient complaining of chest pain, we need to keep a few other body systems in mind.
The Cardiovascular system: Notice that I didn't say “the heart”. This is because, cardiac ischemia in itself is not a condition that exists in isolation. Coronary occlusions are a biproduct of coronary artery disease, which is itself a product of hypertension and dyslipidemia. We need to consider the patient's history, especially if it is significant for CAD, HTN, Diabetes, or hypercoaguable states. I didn't say “the heart”, because occlusions can also occur in other vessels. If a blockage occurs in te cerebrovascular circulation, it manifests as a stroke; if it occurs in pulmonary circulation, it manifests as a Pulmonary Embolism. We need to consider the possible cardiovascular risk factors in any potential cardiac patient.
The Respiratory system: Chest pain may not be cardiac in origin, and can originate from the lung tissues themselves. Pneumothorax, hemothorax, and tension pneumothorax will all present with chest pain. COPD and asthma patients often complain of chest “tightness” or discomfort during exacerbations, and periods of bronchoconstriction. A history of previous pulmonary problems, and associated pain should be elicited.
The Musculoskeletal system: Chest wall tenderness can occur with muscular strain, precordial catch syndrome, or costrocondritis. This can be difficult to discern in the field, but palpation and activity history are important factors.
The immune system: Pneumonia presents with diffuse pleuritic chest pain, but it can localize in some cases as well. A history of cough, fevers, and sputum production, in conjunction with a physical exam can assist in ruling this out.
The renal system: Fluid overload, as a result of renal failure may produce chest pain, and it can cause acute heart failure as well. This may lead to a working impression of anterior myocardial infarction. We need to get a history of the patient's renal function, any dialysis, liver disease, or changes in urination in order to consider renal causes.
Beyond the system considerations we should assess all complaints of chest pain using NOPQRST. In my symptom to diagnosis series I covered the features of common causes of chest pain. Using the standard assessment and vital signs, including 12-lead ECG, we can work through our differential. We also want to look at associated symptoms.
Dyspnea: This is a common finding in several pathologies. We can see dyspnea in ACPE, MI, Dysrhythmia, PE, Pneumothorax, Pneumonia, COPD, and in musculoskeletal conditions that limit chest wall expansion. It is not specific to cardiac causes, but it is relatively sensitive and should be considered a red flag.
Cough: A new productive cough can occur with ACPE, and Pneumonia. ACPE is most commonly caused by an Anterior MI.
Nausea: Nausea in the setting of chest pain is sensitive for MI and has a high degree of specificity as well.
Fever or chills: Should send us leaning toward Pneumonia.
Diaphoresis: Cool, pale, diaphoretic skin signs are actually more specific to a cardiac event than any other sign. They represent hypoperfusion of the tissues and a catecholamine surge that occurs in response to diminished cardiac output.
Recent travel, hospitalization, or surgery: These in conjunction with other factors such as hormone replacement, smoking, pregnancy, or recent vascular injury, all contribute to hypercoaguable state. Patients in this category are high risk for DVT and Pulmonary Embolism.
They physical assessment should involve auscultation of lung sounds to assess for rales, wheezes, or rhonchi, all of which can affect our differential. Heart sounds are helpful too, but only if you are in the habit of listening to them, and are adept at telling normal from abnormal. Palpation of the chest wall, and assessment for changes in pain intensity with deep inspiration are also important assessment features. Vitals including 12-lead ecg should be performed early.
Just as with any complaint, we need to consider all of the factors that could contribute to chest pain. The associated symptoms are key in narrowing potential causes. A thorough exam may seem like a lot to do, but it really only takes a few minutes and can significantly affect treatment.
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