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| ==Overview==
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| ==FIRE: Focused Initial Rapid Evaluation==
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| A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
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| <span style="font-size:85%">Boxes in the salmon color signify that an urgent management is needed.</span>
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| <span style="font-size:85%">'''Abbreviations:''' </span>
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| {{Family tree/start}}
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| {{familytree | | | | | | | | | D01 | | | | | | | | | D01=<div style="text-align: center; width: 15em"> '''Identify cardinal findings that increase the pretest probability of life-threatening chest pain'''</div> <br> <div style="text-align: left; width: 15em"> ❑ </div>}}
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| {{familytree | | | | | | | | | |!| | | | | | | | | | }}
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| {{familytree | | | | | | | | | A01 | | | | | | | | | | A01= <div style="float: left; text-align: left; width: 15em; padding:1em;">'''Does the patient have any of the findings that require urgent management?'''<br>
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| ❑ [[Tachycardia]] <br> ❑ [[Hypotension]]<br>❑ Severe [[dyspnea]]<br> ❑ <br> ❑ </div>}}
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| {{familytree | | | | | | |,|-|-|^|-|-|.| | | | |}}
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| {{familytree | | | | | | B01 | | | | B02 | | | | B01=<div style=" background: #FA8072; text-align: center; width: 15em; padding:1em;"> {{fontcolor|#F8F8FF|'''Yes'''}} </div>| B02= '''No'''}}
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| {{familytree | | | | | | |!| | | | | |!| | | | }}
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| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | C01 | | | | | |!| | | | C01=<div style="float: left; text-align: left; width: 12em">'''Initiate resuscitation measures:''' <br> ❑ Secure airway <br> ❑ Administer oxygen <br> ❑ Secure wide bore IV access <br> ❑ Perform ECG monitor <br> ❑ Monitor vitals continuously <br> ❑ Immediately order an [[ECG|<span style="color:white;">ECG</span>]]</div>}}
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| {{familytree | | | | | | |!| | | | | C02 | | | | | C02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> '''[[Continue with the complete diagnostic approach below]]''' </div>}}
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| {{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | | | | | G01 | | | | | | | | | G01=<div style="text-align: center; width: 15em; padding:1em;">'''[[ECG|<span style="color:white;">ECG</span>]] findings'''</div>}}
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| {{familytree | | | | | |,|-|^|-|-|-|-|-|-|-|-|-|-|-|.| }}
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| {{familytree | | | | | B01 | | | | | | | | | | | | B02 |B01='''Presence of ST elevation'''|B02='''Absence of ST elevation'''}}
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| {{familytree | | | | | |!| | | | | | | | | | | | | |!| | | | | | | | }}
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| {{familytree | |,|-|-|-|+|-|-|-|.| | | |,|-|-|-|v|-|^|-|v|-|-|-|.| | }}
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| {{familytree | C01 | | C02 | | C03 | | |!| | | |!| | | |!| | | |!| | C01=<div style="float: left; text-align: left; width: 12em; padding:1em;">'''Does the patient have both of the following:'''<br>
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| ❑ There is ST elevation in a limited number of leads that fits the anatomic distribution of a coronary artery (examples would include but are not limited to leads 2,3,F, or Leads v1-v4)<br>
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| ❑ PR depression is absent </div>
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| | C02= <div style="float: left; text-align: left; width: 12em; padding:1em;"> ❑ Evidence of [[LBBB]] </div> | |
| | C03=<div style="float: left; text-align: left; width: 15em; padding:1em;"> '''Does the patient have any of the following:''' <br>
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| ❑ There is ST elevation in multiple leads that does not follow an anatomic distribution of coronary arteries (ST elevation is diffuse)<br>
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| ❑ PR Depression is present <br>
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| ❑ PR elevation in lead aVR is present </div>}}
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| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | }}
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| {{familytree | C01 | | C02 | | C03 | | C04 | | C05 | | C06 | | C07 | C01= '''[[STEMI]]'''| C02= '''[[LBBB]]'''| C03= '''[[Pericarditis]]''' | C04= '''[[Aortic dissection]]'''| C05= '''[[Pulmonary embolism]]'''| C06= '''[[Tension pneumothorax]]'''| C07= '''[[Esophageal rupture]]'''}}
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| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | }}
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| {{familytree | D01 | | D02 | | D03 | | D04 | | D05 | | D06 | | D07
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| | D01= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
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| ❑ The pain is described as a heaviness or crushing sensation <br>
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| ❑ Pain radiating to the left arm <br>
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| ❑ Elbow pain <br>
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| ❑ Shortness of breath or dyspnea <br>
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| ❑ Nausea and vomiting <br>
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| ❑ Diaphoresis <br>
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| ❑ An elevation of the CK MB enzyme <br>
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| ❑ An elevation of the troponin enzyme <br>
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| ❑ An elevation of the myoglobin </div>
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| | D02= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | |
| ❑ The pain is described as a heaviness or crushing sensation <br>
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| ❑ Pain radiating to the left arm <br>
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| ❑ Elbow pain <br>
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| ❑ Shortness of breath or dyspnea <br>
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| ❑ Nausea and vomiting <br>
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| ❑ Diaphoresis <br>
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| ❑ An elevation of the CK MB enzyme <br>
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| ❑ An elevation of the troponin enzyme <br>
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| ❑ An elevation of the myoglobin </div>
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| | D03=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
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| ❑ Pleuritic pain <br>
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| ❑ Chest pain that is positional <br>
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| ❑ A viral syndrome <br>
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| ❑ Fever <br>
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| ❑ Cough <br>
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| ❑ A pericardial rub <br>
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| ❑ Presence of tamponade </div>
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| | D04= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
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| ❑ Back pain <br>
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| ❑ Diminution or absence of pulse <br>
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| ❑ Coma <br>
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| ❑ Altered mental status <br>
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| ❑ CVA <br>
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| ❑ Vagal episode <br>
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| ❑ Evidence of ischemia <br>
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| :❑ Splanchnic ischemia <br>
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| :❑ Renal insufficiency <br>
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| :❑ Lower extremity ischemia <br>
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| :❑ Focal neurologic deficits </div>
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| | D05= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | |
| ❑ Shortness of breath <br>
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| ❑ Chest pain <br>
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| ❑ Dyspnea <br>
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| ❑ Anxiety <br>
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| ❑ Pleuritic chest pain </div>
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| | D06= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br> | |
| ❑ Sudden shortness of breath <br>
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| ❑ Cyanosis <br>
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| ❑ Penetrating chest wound <br>
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| ❑ Flopping sound <br>
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| ❑ Following a medical procedure <br>
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| ❑ Patient on mechanical ventilation </div>
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| | D07=<div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
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| ❑ Vomiting <br>
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| ❑ Lower chest pain <br>
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| ❑ Cervical subcutaneous emphysema <br>
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| ❑ Overindulgence in alcohol <br>
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| ❑ Overindulgence in food </div>}}
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| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }}
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| {{familytree | E01 | | E02 | | E03 | | E04 | | E05 | | E06 | | E07 | E01= [[STEMI resident survival guide|Click here for the detailed management]]| E02= [[STEMI resident survival guide|Click here for the detailed management]]| E03= [[Pericarditis resident survival guide|Click here for the detailed management]]| E04= [[Aortic dissection resident survival guide|Click here for the detailed management]]| E05= [[Pulmonary embolism resident survival guide|Click here for the detailed management]]| E06= [[Tension pneumothorax resident survival guide|Click here for the detailed management]]| E07= [[Esophageal rupture resident survival guide|Click here for the detailed management]]}}
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| {{familytree/end}}
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| {{Family tree/end}}
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| <br><br>
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| ==Complete Diagnostic Approach==
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| A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.
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| <span style="font-size:85%"> '''Abbreviations:''' </span>
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| {{familytree/start}}
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| {{familytree | | | | | | | A01 | | A01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterize the chest pain:'''<br>
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| ❑ Heaviness or crushing sensation (suggestive of myocardial isquemia) <br>
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| ❑ [[Pleuritic pain]]
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| : ❑ Sharp or knife-like
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| : ❑ Increases with [[respiratory movements]]
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| ❑ <br> ❑ <br>
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| '''Onset'''<br>
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| ❑ Sudden <br>
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| ❑ <br>
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| '''Location'''<br>
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| ❑ Radiating to left arm, neck and/or jaw (suggestive of myocardial ischemia) <br>
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| ❑ Interscapular (suggestive of [[aortic dissection]] <br>
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| ❑ <br>
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| ❑ <br>
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| '''Activity prior''' <br>
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| ❑ </div>}}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | A01 | | A01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Characterize the associated symptoms:'''<br>
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| ❑ Altered mental status<br>
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| ❑ Shortness of breath <br>
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| ❑ Nausea and vomiting <br>
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| ❑ Dizziness <br>
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| ❑ Palpitations <br>
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| '''Suggestive of cardiac origin'''
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| ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> ❑ <br> </div>}}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | L01 | | L01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Inquire about past medical history:'''<br>
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| ❑ Previous episodes<br>
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| ❑ Cardiovascular disease
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| ❑ Recent medical procedures
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| ❑ Neurological diseases
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| ❑ Recent [[trauma]]
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| ❑ Alcohol intake </div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | B01 | | B01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Identify possible triggers:''' <br>
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| </div>}}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 20em; padding:1em;"> '''Examine the patient:'''
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| '''Vitals'''<br>
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| ❑ [[Heart rate]]
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| ❑ [[Blood pressure]]<br>
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| ❑ [[Respiratory rate]]
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| '''Cardiovascular'''<br>
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| '''Respiratory''' <br>
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| ❑ [[Rales]] (suggestive of [[HF]]) <br>
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| '''Neurologic'''<br></div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | G01 | | G01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order labs and tests:''' <br> ❑ [[EKG]] ''(most important initial test)''
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| ❑ [[Electrolytes]]
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| ❑ [[Glucose]] (rule out [[hypoglycemia]]) <br> ❑ [[ABG]]
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| </div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | H01 | | H01= <div style="float: left; text-align: left; width: 20em; padding:1em;">'''Order imaging studies:'''<br> ❑ '''[[Echocardiography]]''' </div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree/end}}
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| ==Treatment==
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| Shown below is an algorithm summarizing the therapeutic approach to chest pain based on the
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| <span style="font-size:85%">'''Abbreviations:''' </span>
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| ==Do's==
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| * <br>
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| *
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| ==Don'ts==
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| *
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| ==References==
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| {{Reflist|2}}
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| [[Category:Cardiology]]
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| [[Category:Resident survival guide]]
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| [[Category:Up-To-Date]]
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| [[Category:Emergency]]
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| {{WikiDoc Help Menu}}
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| {{WikiDoc Sources}}
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