There is no getting around chest pain when you work in the ED, so we might as well embrace it with zeal and gusto. Within this one symptom there are several potentially lethal diagnoses (MI, PE, dissection). So we must be very careful in our workups and diligent in our documentation. To that end, below is my chest pain medical decision making (MDM) for a patient with a fully negative evaluation.
Chest Pain MDM
Presentation with the above described chest pain. Differential diagnosis includes but is not limited to: ACS, pneumonia, PE, pneumothorax, pulmonary edema/CHF, aortic dissection, pericarditis, intra-abdominal process.
ED course: [ ]
EKG and history do not support the diagnosis of pericarditis. Point of care limited bedside ultrasound shows no pericardial effusion.
There is no evidence of pneumothorax or infiltrate on CXR.
Aortic dissection considered, but presenting symptoms felt uncharacteristic, chest X-ray shows no evidence of mediastinal widening and there are strong, equal and symmetric pulses. Given the current presentation, aortic dissection is felt unlikely.*
History, Chest X-ray, and exam do not suggest pulmonary edema/congestive heart failure
Pulmonary embolism was considered but felt unlikely due to the compendium of presenting elements leading to a low pre-test probability followed by a negative PERC rule. All 8 of the rule out PERC criteria were present including: Age<50, HR <100, O2 sat > 94%, no recent trauma/surgery, no hemoptysis, no exogenous hormone use, no clinical signs suggestive of DVT, no hx DVT/PE. Given the above, there is a <2% risk of PE and I feel that no further diagnostic testing is needed.**
Intra-abdominal pathology felt unlikely given benign/non tender abdominal exam.
Acute coronary syndrome is considered but there are negative serial biomarkers, no acute ischemic EKG changes, and the patient has a low HEART score. Based on this, I think that there is low risk for short-term major adverse cardiac event. I have discussed this with the patient and reviewed options for inpatient and outpatient management. The patient verbalizes an excellent understanding of the above including presence of small risk of short-term major adverse cardiac event even in the setting of low HEART score, negative cardiac biomarker, and compendium of elements of this presentation. The patient wishes to pursue further workup as an outpatient.
Nuance of this MDM
* Documenting my thought processes around dissection has always troubled me. Since there is no great easy to do/low radiation rule-out test (D-dimer is questionable, CXR can notoriously be normal, exam findings can be unreliable), I just insert what I’m actually thinking — which is what we’re supposed to be doing with these things in the first place. If you have a more skillful approach, please share!
** For PE, if the patient falls out of PERC, I replace the above phrase with their Wells score and D-dimer level (as long as they’re not high risk and may have just gone straight to CT). It looks something like this:
-Low risk Wells Score.
-D dimer 1200
-Pt underwent CT chest which was negative for PE.
The formatting above, using dashes followed by short phrases, is something I learned from my partner Dr. Youngblood. I used to dictate flowery paragraphs explaining in great detail the intricate decision making that went into each action. This ‘bulleted’ framework proved more efficient both in time spent (not to mention fewer words so fewer Dragon errors) as well as being easier to see what I was doing (nothing buried in a paragraph).
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