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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 red 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"> ❑ Sudden onset <br> ❑ <br> ❑ <br> ❑ Related physical exertion <br> </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>❑ [[Altered mental status]]<br>❑ Severe [[dyspnea]] <br> ❑ [[Oliguria]] <br> ❑ [[Cold extremities]]</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|-|-|-|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>
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| | 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 | | C08 | |C01= '''[[STEMI]]'''| C02= '''[[LBBB]]'''| C03= '''[[Pericarditis]]''' | C04='''[[Angina]]'''|C05= '''[[Aortic dissection]]'''| C06= '''[[Pulmonary embolism]]'''| C07= '''[[Tension pneumothorax]]'''| C08= '''[[Esophageal rupture]]'''}}
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| {{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| }}
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| {{familytree | D01 | | D02 | | D03 | | D04 | | D05 | | D06 | | D07 | | D08 | |
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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>
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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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| | 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> | |
| ❑ <br>
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| ❑ <br>
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| ❑ <br>
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| ❑ <br></div>
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| | D05= <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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| | D06= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
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| ❑ 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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| | D07= <div style="float: left; text-align: left; width: 12em; padding:1em;"> '''Look for supportive signs and symptoms:''' <br>
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| ❑ 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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| | D08=<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 | | E08 | 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= [[Angina]]| E05= [[Aortic dissection resident survival guide|Click here for the detailed management]]| E06= [[Pulmonary embolism resident survival guide|Click here for the detailed management]]| E07= [[Tension pneumothorax resident survival guide|Click here for the detailed management]]| E08= [[Esophageal rupture resident survival guide|Click here for the detailed management]]}}
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| {{familytree/end}}
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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: 25em; padding:1em;">'''Characterize the chest pain:'''<br>
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| '''Non-specific 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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| <br>
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| '''Symptoms suggestive of cardiac etiology'''<br>
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| ❑ Heaviness or crushing sensation (suggestive of [[myocardial isquemia]]) <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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| ❑ Epigastric pain (suggestive of inferior MI)<br>
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| ❑ Sweating <br>
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| ❑ Palpitations <br>
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| ❑ Pain with exertion <br><br>
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| '''Symptoms suggestive of pulmonary etiology'''<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> ❑ <br> ❑ <br> ❑ <br> ❑ <br>
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| '''Symptoms suggestive of gastrointestinal etiology'''<br>
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| ❑ Burning sensation (suggestive of GERD) <br> ❑ Colicky (suggestive of [[cholelithiasis]]) <br> ❑ Epigastric pain <br>❑ <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: 25em; 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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| : ❑ <br>
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| : ❑ <br>
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| ❑ Recent medical procedures <br>
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| : ❑ <br>
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| : ❑ <br>
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| ❑ Pulmonary disease<br>
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| : ❑ <br>
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| : ❑ <br>
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| ❑ Neurological diseases<br>
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| ❑ Recent [[trauma]]<br>
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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: 25em; padding:1em;">'''Identify possible triggers:''' <br>
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| ❑ <br> ❑ <br> </div>}}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | Z01 | | Z01= <div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Examine the patient:'''
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| '''Vitals'''<br>
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| ❑ Temperature ([[pericarditis]], [[pleuritis]], [[fever]] can precipitate ischemic attacks)<br>
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| ❑ Absent or decreased pulses in limbs ([[aortic dissection]] all four limbs), [[tachycardia]] ([[pulmonary embolism]])<br>
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| ❑ Blood pressure in both the arms ([[aortic dissection]])<br>
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| '''Neck'''<br>
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| ❑ Elevated [[jugular venous pulse]]<br>
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| '''Cardiovascular examination'''<br>
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| ''' Auscultation'''<br>
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| ❑ Third and fourth heart sound<br>
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| ❑ [[Carotid bruit]] <br>
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| ❑ [[Pericardial rub]] ([[pericarditis]])<br>
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| ❑ Murmur (systolic murmur in [[hypertrophic cardiomyopathy]], [[aortic stenosis]])
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| <br>
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| '''Respiratory examination'''<br>
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| ❑ [[Palpation]] - shift in trachea from midline ([[tension pneumothorax]])<br>
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| ❑ [[Auscultation]] - decreased breath sound ([[pulmonary edema]]), pleural rub ([[pleuritis]], [[pneumonia]])<br>
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| '''Abdominal examination'''<br>
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| ❑ Inspection, palpation and auscultation to evaluate for gastrointestinal etiologies of chest pain<br>
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| ❑ [[Rectal examination]] - occult bleeding ([[peptic ulcers]])<br>
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| '''Neurological examination'''<br>
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| ❑ [[Cerebrovascular accident]]s ([[aortic dissection]])<br>
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| ❑ [[Paraplegia]]</div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | G01 | | G01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Order labs and tests:''' <br> ❑ [[EKG]] ''(most important initial test)'' <br> ❑ [[Electrolytes]] <br> ❑ [[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: 25em; padding:1em;">'''Order imaging studies:''' <br> ❑ [[Chest X-ray]] <br> ❑ [[Echocardiography]] </div> }}
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| {{familytree | | | | | | | |!| | | }}
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| {{familytree | | | | | | | U01 | | U01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Does the chest pain has any of the following findings suggestive of cardiac etiology?''' <br> ❑ <br> ❑ <br> ❑ <br> </div> }}
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| {{familytree | | | |,|-|-|-|^|-|-|-|.| | | }}
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| {{familytree | | | I01 | | | | | | I02 | | | I01= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''YES''' </div> | I02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''NO''' </div>}}
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| {{familytree | | | |!| | | | | | | |!| |}}
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| {{familytree | | | J01 | | | | | | J02 | | J01= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Does the EKG has ST elevation?''' </div> | J02=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Determine the non-cardiac etiology based on the physical examination and tests findings''' </div> }}
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| {{familytree | |,|-|^|-|.| | |,|-|-|^|v|-|-|-|.| | }}
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| {{familytree | K01 | |K02| | K03 | | K04 | | K05| | |K01= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''YES''' </div> | K02= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''NO''' </div>| K03= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''Pulmonary''' </div> | K04= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''Gastrointestinal''' </div>| K05= <div style="float: left; text-align: center; width: 14em; padding:1em;">'''Other''' </div>}}
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| {{familytree | |!| | | |!| | |!| | | |!| | | |!| | |}}
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| {{familytree | L01 | |L02| | L03 | | L04 | | L05 | |L01= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Consider the following:'''<br>
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| '''[[STEMI]]''' <br> ❑ Pain described as a heaviness or crushing sensation <br> ❑ Radiates to the left arm, neck and/or jaw <br> ❑ CK-MB and Troponin elevation <br> ❑ PR depression is absent <br> [[STEMI resident survival guide|Click here for detailed management]]<br><br>
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| '''[[LBBB]]''' <br> ❑ EKG evidence of LBBB
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| : ❑ QRS ≥ 120 ms
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| : ❑ QS or rS in V1
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| : ❑ Monophasic R in I, aVL and V6
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| ❑ Chest pain with same characteristic as STEMI <br> [[STEMI resident survival guide|Click here for detailed management]]<br><br>
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| '''[[Pericarditis]]''' <br> ❑ Diffuse, non-specific ST elevation <br> ❑ PR depression is present <br> ❑ PR elevation in lead aVR is present <br> ❑ <br> ❑ <br> [[Pericarditis resident survival guide|Click here for detailed management]]<br><br></div>
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| | L02= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Consider the following:'''<br> | |
| '''[[Aortic stenosis]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Aortic stenosis resident survival guide|Click here for detailed management]] <br><br>
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| '''[[Aortic dissection]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Aortic dissection resident survival guide|Click here for detailed management]]<br><br>
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| '''[[Unstable angina/NSTEMI]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[NSTEMI angina resident survival guide|Click here for detailed management]]<br><br>
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| '''[[Stable angina]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Stable angina resident survival guide|Click here for detailed management]]<br><br></div>
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| | L03=<div style="float: left; text-align: left; width: 14em; padding:1em;">'''Consider the following:'''<br>
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| '''[[Pulmonary embolism]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Pulmonary embolism resident survival guide|Click here for detailed management]] <br><br>
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| '''[[Spontaneous pneumothorax]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Spontaneous pneumothorax resident survival guide|Click here for detailed management]]<br><br>
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| '''[[Tension pneumothorax]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Tension pneumothorax resident survival guide|Click here for detailed management]]<br><br>
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| '''[[Pulmonary hypertension]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Pulmonary hypertension resident survival guide|Click here for detailed management]]<br><br>
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| '''[[Pleuritis]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Pleuritis resident survival guide|Click here for detailed management]]<br><br></div>
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| | L04= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Consider the following:'''<br>
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| '''[[GERD]]''' <br> ❑ Burning sensation from the epigastrium towards the throat <br> ❑ <br> ❑ <br> [[GERD resident survival guide|Click here for detailed management]] <br><br>
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| '''[[Peptic ulcer]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Peptic ulcer resident survival guide|Click here for detailed management]]<br><br>
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| '''[[Pancreatitis]]''' <br> ❑ Epigastric pain radiating to the back <br> ❑ <br> ❑ <br> [[Pancreatits resident survival guide|Click here for detailed management]]<br><br>
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| '''[[Cholelithiasis]]''' <br> ❑ RUQ pain associated with meals <br> ❑ Positive [[Murphy sign]] <br> ❑ <br> [[Cholelithiasis resident survival guide|Click here for detailed management]]<br><br>
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| '''[[Esophageal spasm]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Esopagheal spasm resident survival guide|Click here for detailed management]]<br><br>
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| '''[[Mallory-Weiss]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Esopagheal spasm resident survival guide|Click here for detailed management]]<br><br></div>
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| | L05= <div style="float: left; text-align: left; width: 14em; padding:1em;">'''Consider the following:'''<br>
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| '''[[Musculoskeletal pain]]''' <br> ❑ Pain on palpation of costochondral joints <br> ❑ Exacerbated by chest wall movements <br> ❑ <br> [[Click here for detailed management]] <br><br>
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| '''[[Herpes zoster]]''' <br> ❑ Burning pain localized in a dermatome <br> ❑ Unilateral vesicular rash <br> ❑ <br> [[Click here for detailed management]] <br><br>
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| '''[[Psychiatric conditions]]''' <br> ❑ <br> ❑ <br> ❑ <br> [[Click here for detailed management]]<br><br></div>}}
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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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