Francais | English | Espanõl

Chest pain

From Wikipedia, the free encyclopedia

Jump to: navigation, search
Name of Symptom/Sign:
Chest pain
Classifications and external resources
ICD-10 R07
ICD-9 786.5

In medicine, chest pain is a symptom of a number of conditions and is generally considered a medical emergency, unless the patient is a known angina pectoris sufferer and the symptoms are familiar (appearing at exertion and resolving at rest, known as "stable angina"). When the chest pain is not attributed to heart disease, it is termed non-cardiac chest pain.

Contents

[edit] Causes

[edit] Cardiopulmonary

Important cardiovascular and pulmonary causes of chest pain:

[edit] Other causes

Other causes of chest pain include:

High abdominal pain may also mimick chest pain.

[edit] Analysis

As in all medicine, a careful medical history and physical examination is essential in separating dangerous and trivial causes of disease, and the management of chest pain is often done on specialised units (termed medical assessment units) to concentrate the investigations. A rapid diagnosis can be life-saving and often has to be made without the help of X-rays or blood tests (e.g. aortic dissection). Occasionally, visible medical signs will direct the diagnosis towards particular causes, such as Levine's sign in cardiac ischemia. Generally, however, additional tests are required to establish the diagnosis.

An emergency medicine doctor will also focus on recent health changes, family history (premature atherosclerosis, cholesterol disorders), tobacco smoking.

Features of the pain suggest of cardiac ischaemia are describing the pain as heaviness; radiation of the pain to neck, jaw or left arm; sweating; nausea; palpitations; coming on exertion; dizziness; shortness of breath and a "sense of impending doom."

On the basis of the above, a number of tests may be ordered:

[edit] Interpretation

In finding the cause, the history given by the patient is often the most important tool. In angina pectoris, for example, blood tests and other analyses are not sensitive enough (Chun & McGee 2004). The physician's typical approach is to rule-out the most dangerous causes of chest pain first (eg: heart attack, blood clot in the lung, aneurysm). By sequential elimination or confirmation from the most serious to the least serious causes, a diagnosis of the origin of the pain is eventually made. Often, no definite cause will be found, and the focus in these cases is on excluding severe diseases and reassuring the patient. If acute coronary syndrome ("unstable angina") is suspected, many patients are admitted briefly for observation, sequential ECGs, and determination of cardiac enzyme levels over time (creatine kinase|CK-MB,troponin or myoglobin) On occasion, later out-patient testing may be necessary to follow-up and make better determinations on causes and therapies.

[edit] Admission Orders for Cardiac Patients

O Chest Pain O Unstable Angina O Acute Coronary Syndrome O Acute Myocardial Infarction O Heart Failure

Admit to: O Inpatient or O Outpatient 

    Circle      CCU	 ACU      Medical

1.Diet Orders: 

 O   NPO
 O  Sodium Restricted 2 gm per 24 hour      
      O  Heart Healthy
      O  Fluid Restricted ________ml per 24 hrs 
      O  ADA

2.Laboratory Orders: 

 O  CBC 				
 O  Basic metabolic panel q AM x __________ 
 O  CPK, Troponin I, Myoglobin  now, in 6hrs,    and in 12 hrs	
 O  Lipid Panel	
 O  BNP level now & __________		
 O  Digoxin Level]
   Other _________________________


3. Pharmacy Orders: 

 O  IV Fluids ___________ at ____ml per hr
                          x ________ hours

 O Nitroglycerin 0.4 mg sublingual every 5min    prn chest pain x 3 doses (Obtain STAT 12 lead ECG,and notify MD)
 O  Nitroglycerin in 5% Dextrose 100mcg/ml (Tridil) intravenous solution; titrate to control  angina. Start at 10 mcg/min. Maintain Blood Pressure greater than _______________.

 O  Morphine Sulfate 2 mg intravenously, may     repeat every 5 minutes x 2 doses (total 6 mg)
 O  Potassium Chloride _____mEq by mouth         every ______________

O Digoxin LOAD 0.25 mg IV every 6 hours x 4 doses O Digoxin 0.25 mg by mouth daily or _____________ O Digoxin 0.125 mg by mouth daily or_________________________ 

                 Anticoagulation

O Aspirin 325 mg by mouth daily ¨ GIVEN IN ED O Aspirin 81 mg by mouth daily ¨ GIVEN IN ED O Clopidogrel (Plavix) 300 mg by mouth loading dose O Clopidogrel (Plavix )75 mg by mouth daily


Beta-Blocker Hold for Systolic BP less than 90 or Heart Rate less than 60 and/or if on pressor agent. O Carvedilol (Coreg) 3.125 mg by mouth twice daily or ________mg by mouth every _________ O Metoprolol (Lopressor) 5 mg intravenous every 5 minutes X 3 doses (total 15 mg) GIVEN IN ED O Metoprolol (Lopressor) 12.5 mg by mouth four times daily for 2 days, then Metoprolol 25 mg by mouth twice daily O Other: _____________________________

Statin O Simvastatin (Zocor) 40 mg by mouth daily at bedtime O Other_______________________________________

Anticoagulation O Dalteparin (Fragmin) 120 units/kg (max 10,000 units) subcutaneously twice daily (round dose per pharmacy) O Heparin (refer to pre-printed order “Adult Cardiac-Dose Heparin” O Platelet Inhibitor (IIB,IIIA inhibitor) (Refer to pre-printed order “Platelet Inhibitor”)

Angiotensin-Converting Enzyme (ACE) Inhibitor Hold for SBP less than 90 O Captropril (Capoten) 6.25 mg by mouth every 8 hours O Enalapril (Vasotec) 2.5 mg by mouth twice daily O Lisinopril (Zestril) 5 mg by mouth daily O Ramipril (Altace) 2.5 mg by mouth twice daily. O Other ____________________________

Diuretics O Furosemide (Lasix) __________mg____________ every ________________ O Metolazone (Zaroxolyn) 5 mg by mouth x 1 dose or __________mg every ______________ O Spironolactone (Aldactone) 25 mg by mouth daily O Other ___________________

4. Nursing/Care Orders: 1. Vital Signs/Pulse Oximetry/Pain Scale on admit and q 4 hours or more frequently as warranted by patient condition/symptoms. 2. Cardiac monitor, initiate ACU/CCU routine orders. (For CCU/ACU patients only) 3. Strict I & O. 4. Weight on admission and daily in kilograms. 5 Activity as tolerated.

5. Diagnostic Studies: ECG now (if not done in ER), in AM, and with chest pain recurrence. O PA & Lateral Chest X-Ray O Echo within 24 hours of admission Indication:__________________________________ O Schedule Exercise Test O Schedule ETT with nuclear imaging O Schedule Heart Catheterization for __________________________________ O Other _______________

6. Patient Education: Cardiac Education 

           Dietary Education
           Smoking Cessation referral 
           O  Exercise prescription 
           O  Exercise restrictions_______________________________________________________

Dr. _________________will assume patient care once admitted. Call him/her for further orders, clarification of orders or changes in patient condition.


[edit] References

  • Chun A, McGee S (2004). "Bedside diagnosis of coronary artery disease: a systematic review.". Am J Med 117 (5): 334-43. PMID 15336583.
  • Ringstrom E, Freedman J (2006). "Approach to undifferentiated chest pain in the emergency department: a review of recent medical literature and published practice guidelines.". Mt Sinai J Med 73 (2): 499-505. PMID 16568192. Full text (PDF)
  • Butler K, Swencki S (2006). "Chest pain: a clinical assessment.". Radiol Clin North Am 44 (2): 165-79, vii. PMID 16500201.
  • Haro L, Decker W, Boie E, Wright R (2006). "Initial approach to the patient who has chest pain.". Cardiol Clin 24 (1): 1-17, v. PMID 16326253.
  • Fox M, Forgacs I (2006). "Unexplained (non-cardiac) chest pain.". Clin Med 6 (5): 445-9. PMID 17080889.

[edit] External links

pl:Ból w klatce piersiowej

Retrieved from "http://en.wikivisual.com/index.php/Chest_pain"
Personal tools