ER Chest Pain Workup

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Chest Pain Presentation:

The most common medical presentation in the ER department is chest pain. If you are a medical student or resident, you may also be interested in the Format for Patient Presentation. When evaluating a patient with chest pain, you only need to ask the patient 3 questions that are relevant to coronary artery disease (CAD):

Chest Pain Questions:

1. Location of the pain.

2. What elicits the chest pain?

3. What relieves the pain?

You need to carefully word these questions because patients will answer these questions differently.

Location:

Chest pain is substernal and sudden on onset in coronary artery disease.

What elicits the chest pain?

Word this question as, "what were you doing right before you had chest pain?" Chest pain in CAD occurs when there is increased cardiac demand, which requires increased blood flow to the heart. But since the offending artery is blocked, blood flow does not occur completely, and this causes ischemia of cardiac tissue resulting in chest pain. The patient may have been lifting something heavy, or climbing a flight of stairs, or walking their dog.

What relieves the chest pain?

You need to break this question in 2 components.

1. For example, if the patient was climbing the stairs right before they had chest pain - you need to ask "when you stopped climbing the stairs, did the pain go away?"

2. If the patient has a known history of CAD, you need to ask the patient, "if you put nitroglycerine under your tongue, does the pain go away?"

In terms of physiology, chest pain goes away when we stop exercising because of decreased cardiac demand. There are a lot of things going on in coronary artery disease - stable and unstable angina, myocardial infarction (both ST elevation and non-ST elevation), etc. Vasodilators like nitroglycerine and hydralazine vasodilate, hence, making it easier for blood to flow, preventing ischemia and chest pain.

Orthopnea

Ask the patient if they use additional pillows in order to sleep, and if the number of pillows needed to sleep on has increased over time. You can also do a quick test at the bed-side. Make the patient lie down on the bed at 0 degrees and carefully watch the patient for about a minute. If you notice the patient becoming short of breath, we're talking orthopnea. Orthopnea, unlike CAD, can be verified quickly at bed side.

Jugular venous distention:

Patients with normal CVP must not have JVD. If they do, it is right sided heart failure because blood is backing up in jugular veins.

Grading edema:

Grading edema using numbers (eg., +3 or +2) is useless because different physicians may see edema differently. One proper way of grading edema is to mention the level of edema using phrases like "edema up to the knee," or "edema up to the ankle."

Additional Reading:

Random USMLE Facts

1. Random USMLE Facts volume 1-1
2. Random USMLE Facts volume 2-1
3. Random USMLE Facts volume 3-1
4. Random USMLE Facts volume 4-1
5. Random USMLE Facts volume 5-1
6. Random USMLE Facts volume 6-1
7. Random USMLE Facts volume 7-1
8. Random USMLE Facts volume 8-1
9. Random USMLE Facts volume 9-1
10. Random USMLE Facts volume 10-1
11. Random USMLE Facts volume 11-1
12. Random USMLE Facts volume 12-1

General and Systemic Examinations

1. General Examination for Internal Medicine
2. Jugular Venous Distention Workup
3. ER Chest Pain Workup
4. Format for Patient Presentation
5. Pulmonary Examination for Internal Medicine
6. Cardiac Examination for Internal Medicine
7. Abdominal Examination for Internal Medicine
8. Cranial Nerve Reflexes
9. Motor System Examination
10. Random Sensory System Facts
11. Random Stroke Facts

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USMLE Step 2 CS Videos

1. Video of Cardiology Examination in a Clinical Setting
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3. Video of Pulmonology Examination in a Clinical Setting
4. Video of Musculoskeletal Examination in a Clinical Setting
5. Video of Abdominal Examination in a Clinical Setting
6. Video of HEENT Examination in a Clinical Setting
7. Video and Description of Rinne Hearing Test
8. Video and Description of Weber Hearing Test

USMLE Laboratory (lab) Values

1. USMLE Blood Lab Values
2. USMLE Cerebrospinal Lab Values
3. USMLE Hematologic Lab Values
4. USMLE Sweat and Urine Lab Values

Medical Images

Useful Medical Images & Diagrams (link opens in a new window)

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