There's a Patient in Bed 4 with Chest Pain

Armed with these sparse details along with the patient's age and gender, you begin your 30 second walk to Bed 4. Is this patient in the midst of a heart attack, or simple indigestion? By the time you pull back the curtain to introduce yourself, you have a differential diagnosis in mind and are ready to ask the questions and perform the maneuvers that will tell these causes apart. Thirty more seconds pass and you've assessed whether the etiology of the patient's chest pain is likely cardiac or non-cardiac, and triaged them as green, yellow, or red.

"Well...the chest pain is going to be due to a cardiac cause because we're in our cardiology block right now." - Medical student in their first session with Dr. Deason.

As a healthcare provider, you will often finding yourself not getting much more information than the patient's age, gender, chief complaint, and bed number. Cases evolve from there one step at a time, one piece of information at a time. The questions you ask, exam maneuvers you perform, and labs/imaging you order will all be guided by your differential diagnosis.

Cardiac or Non-Cardiac?

History

For the patient history, gather the OPQRST-ADA for the patient's pain.

• Onset: sudden vs. gradual
• Provocation: related to exertion, stress, or meals
• Quality: descriptions like sharp, dull, burning, crushing, or tightness
• Radiation: localized vs. travels to arm, jaw, back, or shoulder
• Severity: pain scale 1-10
• Timing: duration as well as constant or intermittent
• Aggravating or Alleviating Factors: what makes the pain better or worse
• Drugs: what's been taken for the pain so far and how effective has it been
• Associated Symptoms: presence of dyspnea, diaphoresis, nausea, vomiting, syncope, palpitations, or cough

Cardiac: sudden onset, crushing/squeezing pain, radiation to jaw/arm, triggered by exertion/stress, relieved by rest/nitroglycerin.

Non-Cardiac: sharp or burning pain, associated with meals or position changes, localized without radiation.

Physical Examination

• Vital Signs: Blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature.
• Cardiac Exam: Heart sounds (murmurs, gallops), jugular venous distension, peripheral edema.
• Pulmonary Exam: Breath sounds, percussion (dullness, hyperresonance), and signs of respiratory distress.
• Abdominal Exam: Signs of gastrointestinal issues like tenderness, distension.
• General Appearance: Overall distress, cyanosis, or pallor.

Cardiac: Abnormal heart sounds, signs of heart failure (JVD, edema), significant changes in vital signs (tachycardia, hypotension).

Non-Cardiac: Normal heart sounds, localized tenderness on palpation, normal vital signs.

Initial Diagnostic Tests

• Electrocardiogram (ECG): Look for ischemic changes (ST elevation or depression, T wave inversion), arrhythmias, or signs of right ventricular strain.
• Chest X-ray: Evaluate for pneumothorax, pneumonia, cardiomegaly, or widened mediastinum.
• Blood Tests: Cardiac enzymes (troponin), D-dimer, complete blood count (CBC), basic metabolic panel.

Cardiac: ECG changes, elevated cardiac enzymes.

Non-Cardiac: Normal ECG, normal cardiac enzymes, possible findings on chest X-ray indicative of non-cardiac causes.

Triaging Chest Pain

Green (Low Risk)

• Characteristics: Pain is non-specific, not associated with exertion, and lacks concerning features. No significant abnormalities on physical exam or initial diagnostic tests.
• Examples: GERD, musculoskeletal pain, anxiety-related chest pain.
• Action: Outpatient follow-up, reassurance, and symptomatic treatment.

Yellow (Intermediate Risk)

• Characteristics: Pain with some concerning features but not clearly life-threatening. Mild abnormalities on physical exam or initial diagnostic tests that do not suggest immediate danger.
• Examples: Atypical angina, mild pericarditis, possible pulmonary embolism without severe symptoms.
• Action: Further evaluation in the emergency department, possible admission for observation and additional testing.

Red (High Risk)

• Characteristics: Pain with multiple concerning features suggestive of a life-threatening condition. Significant abnormalities on physical exam or initial diagnostic tests.
• Examples: Acute coronary syndrome (ACS), myocardial infarction (MI), pulmonary embolism with hemodynamic instability, aortic dissection, tension pneumothorax.
• Action: Immediate intervention, rapid diagnostic testing, and stabilization. Admission to an intensive care unit (ICU) or similar high-acuity setting.

Conclusion

No matter where you reside in the chain-of-care, every healthcare provider should be equipped with the skills to discern how urgently a patient's chest pain needs to be addressed. By systematically gathering and analyzing the history, physical exam findings, and initial diagnostics, healthcare providers can effectively prioritize and triage patients with chest pain.

Hone these skills and next time you're sent to the hypothetical Bed 4 for a patient with chest pain, you'll be armed with what you need to ensure timely and appropriate care!