USMLE STEP 2 cs preparation - CHEST PAIN

Chest pain 

HISTORY TAKING :

 

 LIQOR PAAPP- FOR D

Location

Intensity

Quality

Onset(frequency,onset,pain last?,comes and go/intermittent?)

Radiation

Precipitating factor

Alleviating factor

Associated symptoms(nausea ,vomiting, sob,sweating, cough,wheezing,abd pain,diarrhea,constipation,fever) 

Progression

Previous episodes  - FREQUENCY ONSET RELIEVING FACTOR DURATION

Cardiac risk factor (htn,hyperlipidemia,smoking,family hx of early MI)

Pulmonary embolism risk factor (hx of dvt,coagulopathy,malignnacy,recent immobilization)

ROS-THEN FR CS PUB SAW ID 

TRAVEL RECENTLY? trauma?

Headache

Edema

Nausea/vomit

Fever/chills/night sweat

Racing of heart?rash?

Chest pain? / Cough?

SOB

Pain in the joint?

Urinary problems?

Bowel problem?

Sleep pattern(insomnia? pillows to sleep?)

Apetite?

Weight changes?(how much? time?intentional?

Infection (recent?)

D izzy? (if yes,vision problem?)

+ PAM HUGS FOSS

PMH

ALLERGY

MEDICATION (COMPLIANCE,SE?)

HOSPITALIZE HX

URinARY CHANGES

Git changes

Sleep pattern change

Family history

O&G HX

SEXUAL HX

SOCIAL HX(ALCOHOL USE,ILLICIT DRUG,SMOKING(ppd,years, EXERCISE?,DIET?)

 

Diffferntial dignosis: 

  
-MI 

-GERD

-Angina

-costochondritis 

-aortic dissection

-pericarditis

-pneumothorax

-sickle cell ds(acute chest syndrome)

-pneumonia

-esophagitis

-PUD

-esophageal spasm

-costochondritis,

-cocaine induced MI

PE: 

NECK EXAM -JVD ,CAROTID AUSCULTATION 

CVS EXAM -INSPECTION, AUSCULTATION ,PALPATION 

 

PULMONARY EXAM - ASCULTATION ,PALPATION,PERCUSSION 

ABDOMINAL EXAM-AUSCULTATION, PALPATION,PERCUSSION 

EXTREMITIES - CHECK FOR PERIPHERAL PULSES,CHECK BP IN BOTH ARM ,LOOKED FOR EDEMA AND CYANOSIS

Normal CVS documentation example :

CV S1, S2-WNL, RRR,WNL, no RMG.no JVD,no clubbing no edema. Carotid,radial,DP,PT pulse NL & equal B/L. no carotid bruits

Workup : 

-ECG

-CPK-MB ,Troponin

-CXR

-ELECTROLYTES

-CBC

-ECHOCARDIOGRAPHY

-EXERCISE STRESS TEST

-CARDIAC CATHETERIZATION

-D-DIMER

-HELICAL CT

-BARIUM SWALLOW

-UPPER ENDOSCOPY 

-AORTIC ANGIOGRAPHY 

CLOSURE :

-INITIAL DIAGNOSIC IMPRESSION

- MANGEMTN PLAN (FOLLOW UP TEST,LIFESTYLE MODIFICATION(DIET,EXECISE)

-ASK IF PT HAVE ANY OTHER QUESTION

EXAMPLE of closure:

Mr,jones the source of ur pain can be a cardiac problem such as heart attack or angina,or it may be due to acid reflux,lung problems or disorder related to the large blood vessels in your chest. it is crucial that we perform some test to identify the source of your problem . we will start with an ECG and some blood work, but more complex test may be neede as well,in the meantime,istrongly recommend that you stop using cocaine,since use of this drug can lead to a variety of medical problems,including heart attacks.do u have any question for me?

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PATIENT NOTE EXAMPLE

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HISTORY

HPI:

46 yo male c/o substernal chest pain. The pain started 40 minutes before the patient presented to the ED. The pain woke the pt from sleep at 5 am with a steady 7/10 pressure sensation in the middle of his chest that radiate to the left arm,upper back and neck.nothign makes it worse or better. nausea,sweating,dyspnea are also present. Similar episodes have occured during the past 3 months,2-3 times/week. These episodes were precipitated by walking up the staird,strenous exercise,sexual intercourse and heavy meals.pain during this ep was less sevre,lasted 5-10minutes and disspear spontaneously or after taking antacids

ROS: negative except as above

allergies : NKDA

medication : Maalox,diuretic

PMH : htn for 5 years,treated with a diuretic.high cholesterol managed with diet.GERD 10years ago treated with antacids

SH : 1 PPD  for 25 years ;stopped 3months ago.occasional EtOH,occasional cocaine for 10 years (last used ytd afternoon). no regular exercise;poorly adherent to diet.

FH : father died of lung cancer at age 72. mother has peptic ulcers.no early coronary disease

Physical examination :

Pt in severe pain

VS : 165/85,rr 22/min

neck : no JVD nobruits

chest : no tenderness,clear symmetric breath sounds bilaterally

heart : apical impulse not displaced;RRR;normal S1/S2 ,no murmurs,rubs/gallops.

abdomen : soft,nondistended ,nontender ,posittive BS no hepatosplenomegaly

extremities : no edema,peripheral pulses 2+ and symmetric.

differential diagnosis 

diagnosis 1 Myocardiac ischemia or infarction

hx findings:

-pressure like substernal chest pain

-pain radiated to left arm ,upper back and neck

-pain awakens pt at night

diagnosis 2 cocaine induced mi

hx finding

-hx of cocaine use

-last used was ytd afternoon

-pressure like substernal chest pain

diagnosis 3 GERD

-pain in midchest

-previous pain was relieved by antacids

-previous pain occured after heavy meals

diagnostic workup

-ECG

-Cardiac enzymes(CPK,CPK-MB,troponin)

-TTE

-upperendoscopy

-urine toxicology 

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-Hello mr,chen I’m dr chon .i’m ur physician today,nice to meet u .im here to do pe and ask u some question.is that ok?
-R u comfortable in this room?
-May I put this on ur lap?thank u
-Do u mind if i sit down and write while we talk? Thank u

-Mr,chen can u pls tell me how can I help u today? Im very sorry to hear that u r having chest pain I will do everything I can to help u

-Can u pls explain to me what r u experiencing ?

-what this sudden, does this happen over a period of time?

-Can u pls point exactly whr ur pain is ?

-On the scacle of 1-10 ,10 being the worst ,how would u rate the pain? I’m very sorry to hear that sir,it sound like it must be really uncomfortable for u.

-What type of pain r u experiencing?

-When did ur pain begin?

-When the pain begin how long does it last?

-Over the last 2 week is the pain getting better? I’m so sorry to hear the pain is getting worst.

-How often do u get the pain?

-Is there any particular time of the day that u get the pain more?

-Is there any particular activity that causes the pain to be increase?

-Is the pain constant, or does the pain comes n go?

-Does the pain move around anywhere?

-Is there anything make the pain worst? What do I mean by that? does walking up the stairs carrying grocery make it worst?

-Does anything make the pain better?

-Do u find that u r sweating?

-Do u have a difficult time breathing?

-Do u have a difficult time breathing at night?

-Do u find like ur heart racing?

-Do u have a cough?

- Do u found nausuea,I’m sry to hear that sir?

-have u vomited?

- Do u have any diarrhea?

-Do u feel constipated?

-Do u have any pain in ur belly?

- Do u find urself wheezing?

-Is there any pain when u breathing?

-Do u have a sore throat?

-Do u have headache?

-Do u feel dizzy?

- R u tired?

-Do u have rash?

- Have u had  a recent fever?

-Have u have recent infection?

- do u have recent chills?

-Do u get night sweats?

-How mny pillow do u use to sleep with at night?

-Dou have any pain at ur arm?

-Do u have any pain at ur jaw?

-Do u have any pain at ur neck?

-Do u drink a lot caffeine?

-Did u have a lot anxiety in ur life?

-Do u bruise easily??

-Have u have any changes in ur skin/hair?

-Does any particular temperature make u feel uncomfortable,

-y am I asking this question?

-Well sometime there is a gland that sit infront ur neck,when something wrong about the gland ,u feel uncomfortable n cold temperature or hot temperature u will noticed skin changes or hair loss .and that gland is call thyroid. I wan to make sure that thr r no problem with ur thyroid that causing  that chest pain. 

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CHEST PAIN CASE 1:
60y M w/ s/o substernal heavy chest pain radiating to l arm x30min. A/W dyspnea, diaphoresis, nausea. Hx HTN, HLD, smoking.

DDX:

• MI
• GERD,
• angina, 
• costochondritis, 
• aortic dissection, 
• pericarditis, 
• PE, 
•  pneumothorax

W/U:

 EKG, CPK-MB, troponin x3, CXR, CBC, electrolytes, echocardiography, cardiac catherization,D-dimer, helical CT

CASE 2 CHEST PAIN

20y AA F w/ acute o/s severe chest pain xhrs. Hx of multiple previous hospitalizations for pain and anemia management.

 ddx:

• Sickle cell disease-Acute chest syndrome
• pneumonia, 
• PE, 
• MI, 
• pneumothorax,
•  aortic dissection

W/U: 

CBC, reticulocyte count, LDH, peripheral smear, ABG, CXR, CPK-MB, troponin, EKG, CTA-chest w/ IV contrast

 
 CASE 3 CHEST PAIN
46y F w retrosternal burning sensation after heavy meals and when lying down. Relief w antacids.
ddx:

• GERD
• esophagitis, 
• PUD, 
• esophageal spasm, 
• MI, 
• angina

W/U:

 EKG, barium swallow, upper endoscopy, esophageal pH monitoring

CASE 4

57y M w/ retrosternal squeezing pain x2min w exercise. Relieved by rest, not related to food intake.

DDX:

• Angina 
• esophageal spasm, 
•  esophagitis

W/U: 

EKG, CPK-MB, troponin, CXR, CBC, electrolytes, exercise stress test, upper endoscopy/pH monitor, cardiac catherization

 CASE 5

35y F w/ retrosternal stabbing chest pain improving w/ leaning forward worsening with deep inspiration. Hx URI x1wk.

• Pericarditis
•  aortic dissection, 
• MI, 
• costochondritis,
•  GERD, 
• esophageal rupture)

W/U: 

EKG, CPK-MB, troponin, CXR, echocardiography, CBC, upper endoscopy

 CASE 6

71y F w/ acute o/s SOB at rest & pleuritic chest pain. Also tachycardic, hypotensive, tachypneic, mild fever. Recent hx hip replacement surgery.

DDX:

• PE
• pneumonia,
•  costochondritis, 
• MI
• CHF,
•  aortic dissection

W/U:

 EKG, CXR, ABG, CPK-MB, troponin, CBC, chem 7, CTA-chest w/ IV contrast, doppler U/S - legs, D-dimer

 CASE 7

54y M w/ s/o severe chest pain radiating to back. Hx uncontrolled HTN.

DDX:

• Aortic dissection
• MI, 
• pericarditis, 
• esophageal rupture, 
• esophageal spasm, 
• GERD, 
• pancreatitis,
•  fat embolism

W/U

: EKG, CPK-MB, troponin, CXR, CBC, amylase, lipase, TEE, MRI/MRA-aorta, aortic angiography, upper endoscopy

 CASE 8

33y F w/ stabbing chest pain worse w/ deep inspiration relieved by aspirin. Hx URI x1wk. +chest wall tenderness.

DDX;

• Costochondritis
• pneumonia, 
• MI, 
• PE, 
• pericarditis, 
• muscle strain

W/U: 

EKG, CPK-MB, troponin, CXR, CBC