Chest Pain | Medicine Clerkship (Inpatient)

Rationale

Chest pain is an important presenting symptom for a variety of disorders, many of which represent serious medical disorders. Angina pectoris is the most common cardiac source of chest pain which may present classically or in a variant form such as Prinzmetal angina or atypical angina. Distinguishing chest pain of cardiac origin from that occurring as a result of chest wall disorders, pleuropulmonary disorders, aortic dissection, gastrointestinal disorders, and psychogenic states is an important training problem for third-year medical students.

Prerequisite

Prior knowledge, skills and attitudes acquired during the pre-clinical (basic science) years should include:

anatomy of the heart, chest, and abdomen
pathogenesis and pathophysiology of cardiovascular disease
pharmacology of cardiovascular drugs
epidemiology of heart disease
ability to perform a cardiovascular risk assessment
ability to take a medical history and perform a physical exam
ability to understand primary and secondary prevention of cardiovascular disease and be able to communicate it appropriately to all patient groups, including the elderly patient.

Specific Learning Objectives

Knowledge: Students should be able to define and describe:
1. the signs and symptoms of:
  1. right- and left-sided congestive heart failure
  2. ischemic heart disease
  3. valvular heart disease (aortic stenosis, aortic insufficiency, mitral stenosis, mitral regurgitation)
2. signs and symptoms associated with ischemic cardiac pain:
  1. angina pectoris (typical and atypical)
  2. prinzmetal angina (variant angina)
  3. acute myocardial infarction
  4. unstable angina
  5. non-ischemic cardiovascular pain
  6. mitral valve prolapse
  7. dissecting aortic aneurysm
  8. pericardial pain (acute)
  9. cardiomyopathy
3. signs and symptoms associated with chest pain due to GI disorders:
  1. gastroesophogeal reflux
  2. peptic ulcer disease
  3. biliary colic
  4. pancreatitis
4. signs and symptoms associated with chest pain due to pulmonary disorders:
  1. pneumonia
  2. spontaneous pneumothorax
  3. pulmonary embolism
  4. pulmonary hypertension
  5. inflammation of the pleura
5. signs and symptoms associated with chest pain due to musculoskeletal causes:
  1. costochondritis (Tietze’s syndrome)
  2. muscular strain
6. reasons why the following factors are associated with exacerbating chest pain:
  1. anemia
  2. hypoxemia
  3. hypertension
  4. tachyarrhythmia
  5. hyperthyroidism
7. typical blood pressure values that occur with aortic stenosis, aortic insufficiency, and pulsus paradoxicus
8. common abnormalities that can cause paradoxical and fixed splitting of the S2; factors that increase or diminish the intensity of S1
9. the consequences of the following risk factors and their association with heart disease:
  1. hypertension
  2. smoking
  3. lipid abnormalities
  4. age and gender
  5. diabetes mellitus
  6. family history of heart disease
  7. obesity
  8. dietary intake of saturated fat and cholesterol
  9. sedentary lifestyle
10. role of a critical pathway or practice guideline in delivering high quality care for patients hospitalized with ischemic chest pain
11. role of a critical pathway or practice guideline in delivery high quality, cost effective care for outpatients presenting with non-ischemic chest pain
Skills: Students should demonstrate specific skills including:
1. history-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history that differentiates among etiologies of disease, including:
  1. the presence of chest pain (typical, atypical)
  2. dyspnea (resting, exertional, nocturnal)
  3. history of hypertension, valvular heart disease, mitral valve prolapse, rheumatic fever, cardiac murmurs, family history of heartdisease and cardiovascular risk factors
2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease, including:
  1. obtaining an arterial blood pressure
  2. identifying major arterial and venous pulses for abnormalities and the presence of any bruits
  3. examination of the fundus
  4. examining the extremities, to ascertain skin condition, including color and temperature; presence of edema; cyanosis and presence of clubbing
  5. examining the lungs for rales, rhonchi, and decreased breath sounds
  6. inspection and palpation of the anterior chest to identify right- and left heaves and thrills
  7. examining the heart, including rhythm; intensity of heart sounds; presence of murmurs, rubs, gallops, or extra sounds (e.g., clicks). Recognizes the following heart sounds:
    - S1, S2, and normal splitting of the S2
    - abnormal sounds, S3, S4, summation gallop, abnormal splitting of the S2 and mitral valve clicks
    - distinguished ejection from regurgitant systolic murmurs.
    - examining the abdomen, to determine the presence of epigastric or RUQ tenderness, hepatomegaly
3. differential diagnosis: Students should be able to generate a prioritized differential diagnosis recognizing specific history and physical exam findings that suggest ischemic chest pain from nonischemic causes of chest pain, (GI, pulmonary, musculoskeletal, or undetermined)
4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics, as well as patient preferences
  1. laboratory and diagnostic tests should include, when appropriate:
    - blood count
    - specific enzyme tests to determine the presence of cardiac damage
    - electrocardiogram
    - chest x-ray
    - ABG
  2. students should be able to define the indications for and interpret (with consultation) the significance of the results of:
    - echocardiogram
    - exercise stress test and the use of the pretest probability of CAD to interpret results
    - stress thallium (myocardial perfusion radionuclide scan)
    - cardiac catheterization
    - pulmonary angiography
    - V/Q scan
5. communication skills: Students should be able to facilitate the provision of counseling to patients about the following:
  1. smoking cessation
  2. dietary saturated fat and cholesterol reduction
  3. dietary sodium reduction
  4. weight reduction
  5. increased physical activity
  6. students should be able to communicate the diagnosis, treatment plan, and prognosis of the disease to patients and their families, and when appropriate, identify and educate patients about cardiovascular risk factors for disease relative to their age and gender
6. basic procedural skills: Students should be able to perform:
  1. EKG
7. management skills: For each treatment listed below, students should be able to identify indications, action, mechanism, side effects, adverse reactions, and significant interactions of:
  1. medications:
    - digoxin
    - calcium channel blockers
    - beta blockers
    - angiotensin-converting enzyme inhibitors
    - nitrates
    - nitroglycerine
    - aspirin
    - heparin
    - warfarin
  2. students should be able to locate information on the cost of various agents within each class of medications
  3. other therapies:
    - thrombolytic therapy
    - PTCA
    - surgical therapy:
      - CABG
  4. students should be able to access and utilize appropriate information systems and resources to help delineate issues related to chest pain
Attitudes and Professional Behaviors: Students should be able to:
1. understand the emotional impact of a diagnosis of coronary artery disease and its potential effect on lifestyle (work performance, sexual functioning, etc.)