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Site

where is the pain located?

superficial or deep?

S

Onset

How did the pain start?

Is it gradual or sudden?

is it getting worse or better?

O

Character

C

How does it feel?

Stabbing?

Acheing

Burning?

etc.

Radiation

Is it localized?

Or does it radiate?

R

Associations

Is there anything with the pain?

Eg: Dizziness, nausea, vertigo, etc.

A

Time course

Does it get better or worse at certain times?

T

Exacerbating factors

Does it get worse with certain movements?

also include relieving factors

E

Severity

How bad is the pain?

S

Examples

Differential Diagnoses for our case

  • Angina
  • Pericarditis
  • Myocardial infarction
  • Pneumonia

Angina

  • S - Chest
  • O - physical exertion or stress
  • C - tightness, dull, heavy; in women: stabbing, sharp
  • R - arms, neck, jaw, back
  • A - breathlessness, nausea, pain similar to indigestion, tiredness
  • T - stopes when resting
  • E - N/A
  • S - N/A

Pericarditis

  • S - Chest
  • O - sudden
  • C - stabbing pain in chest
  • R - neck, shoulders, arms
  • A - fever, nausea, light headedness, shortness of breath
  • T - N/A
  • E - leaning forward, worse lying down
  • S - N/A

Myocardial infarction

  • S - chest
  • O - sudden
  • C - pressure, tightness, squeezing of heart
  • R - arms (left or both), neck, abdomen, jaw, back (can differ in m/f)
  • A - sweating, light headedness, shortness of breath, nausea, panic, cough
  • T - N/A
  • E - N/A
  • S - N/A

Pneumonia

  • S - chest
  • O - sudden
  • C - N/A
  • R - N/A
  • A - cough, difficulty breathing, fever, loss of appetite, malaise
  • T - N/A
  • E - N/A
  • S - N/A

Scores

Classifications of people into groups

  • TIMI
  • Chad2
  • GRACE (GRACE 2.0)

Thrombolysis in Myocardial infarction (TIMI)

  • risk score for death or ischaemic episodes
  • Factors:
  • age >65
  • aspirin use withn last 7 days
  • 2 angina episode within last 24h
  • ST changes of 0.5 mm
  • elevated serum cardiac biomarkers
  • known coronary artery disease
  • 3 risk factors for coronary artery disease
  • hypertension
  • smoking
  • low HDL
  • diabetes
  • family history

TIMI scores

  • score 0-1 = 4.7%
  • score 2 = 8.3%
  • score 3 = 13.2
  • score 4 = 19.9%
  • score 5 = 26.2%
  • score 6-7 = risk >40.9%

Chads2

  • stroke risk in patients with atrial fibrillation
  • Factors:
  • congestive heart failure history
  • Hypertension
  • Age > 75
  • Diabetes
  • Stroke history
  • up to 18.2% risk for patients with all facotrs present

Grace (Grace 2.0)

  • determines mortality risk of patients with STEMI or unstable angine/NSTEMI
  • Factors:
  • Age
  • Heart rate
  • Systolic BP
  • Creatinine
  • Cardiac arrest
  • ST segment deviation
  • Abonral cadiac anzymes
  • Killip signs/symptoms (CHF, Rales and/or JVD, pulmonary oedema, cardiogenic shock)
  • recommended in NICE guidelines
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