Chest Pain

SUBJECTIVE:
[text]yo [select value="M|F"] presents with chest pain.

Onset [text] prior to evaluation
Onset while: [text]
[select value="no|YES"] <-- Past Cardiac Events
[select value="no|YES"] <-- Previous episodes 
[select value="no|YES"] <-- Similar to prior anginal pain

Associated Pain
Location: [text]
Radiation: [text]
Severity now: [text]
Duration: [text]
Characterized as: [text].
Reproducible: [text]

The pain is relieved with [text]
[select value="no|YES"] <-- OTC NSAID's
[select value="no|YES"] <-- Rest
[select value="no|YES"] <-- Nitroglycerin

The pain is worse with [text]
[select value="no|YES"] <-- supine or leaning forward ( concern for pericarditis)
[select value="no|YES"] <-- Rest
[select value="no|YES"] <-- exertional pain
[select value="no|YES"] <-- pleuritic pain


Associated Symptoms:
[select value="no|YES"] <-- nausea/vomiting
[select value="no|YES"] <-- diaphoresis
[select value="no|YES"] <-- shortness of breath
[select value="no|YES"] <-- Increase in SOB from baseline
[select value="no|YES"] <-- Preyncope


Pertinent PMH
[select value="no|YES"] <-- Coronary Disease
[select value="no|YES"] <-- Cerebrovascular disease
[select value="no|YES"] <-- Diabetes Mellitus
[select value="no|YES"] <-- Peptic Ulcer or GERD
[select value="no|YES"] <-- Chest injury or overuse
[select value="no|YES"] <-- ETOH use
[select value="no|YES"] <-- FH of Heart Dz
[select value="no|YES"] <-- Tobacco Use [text name="variable_1" default="sample text"]
[select value="no|YES"] <-- CKD

Objective:
Vitals:
General: WDWN, NAD [text]
HEENT: Normocephalic, EOMI, no LAD [text]
CV: RRR, no murmurs, rubs or gallops. radial pulse 2+ b/l. [text]
Lungs: CTAB [text]
Abdomen: [text] tenderness to palpation noted [text] 

Assessment/Plan
Patient presents to clinic with [text]
Differential Dx: [text]
Tests:[text]
Treatment: [text]
Follow up: [text]
Patient educated on [text]
Next steps if no improvement: [textarea default="sample text"]

Pt does not have recent prolonged travel, recent trauma, hypercoagulable state, hormonal therapy or hx of blood clots in the family.

Pt denies fever, diaphoresis, rash, palpitations, dyspnea, orthopnea, PND, cough, sputum, hemoptysis, abdominal pain, nausea, vomiting, dysphagia, syncope, lower extremity pain.

Assessment/Plan:
Differential: Heart/ vascular: Angina MI Acute pericarditis Aortic dissection Lungs: Pneumonia PE Pneumothorax. GI: GERD Peptic ulcer disease Pancreatitis Diffuse esophageal spasm. Other: Costochondritis Rib fracture Anxiety Herpes zoster Skin lacerations Muscle strain.

IF Intermediate/High Risk:
<65yo:Order Coronary CT Angiogram (CCTA) to r/o ACS (Good for 2 years)
65+yo: Conduct Stress Test (Treadmill > Pharmacologic)
-If baseline ECG normal then stress w/ ECG
--If baseline ECG abnormal then stress with echo
---If baseline ECG and Echo abnormal then stress with nuclear test

Anything above abnormal → Invasive Coronary Angiography (ICA)
Look For: # of obstructive lesions (AKA >50%), Size/Caliber, and Location/Accessibility
•>=3 vessels, L mainstem OR difficult anatomy → CABG + DAPT
•<3vessels/small/reachable → PCI (DES) + DAPT

Medical Therapy for STABLE Ischemic ♥ Dz:
Aspirin 81mg
Statin: Atorvastatin 40/80mg OR Rosuvastatin 20/40mg
BB: HR Metoprolol, BP: Carvedilol
ACE/ARB
2PY12 Inhibitor: Clopidogrel, Prasugrel, Ticagrelor
+ Possible Anti-Anginal med