User Tools

Site Tools


chestpain_notation

template to assist in the discharge documentation of low risk chest pain

example notations to copy and paste

general conclusive notation

initial statement

No definitive cause for this patient's chest pain was found at this presentation. In particular, there was no evidence to support diagnoses such as aortic dissection, pulmonary embolism, acute coronary syndrome warranting emergent angiography, pericarditis, pneumonia, pneumothorax, shingles, or extra-thoracic causes such as biliary colic.

middle statement

  • copy and paste from individual conditions below to provide further elaboration

final statement

Despite the above, the patient should be further reassessed if their condition changes to ensure there is no delayed evidence to support any of the above, or other conditions which may become apparent with time.

In the interim, the patient has been advised to take regular aspirin 100mg daily, avoid exertion until further investigation of ischaemic heart disease such as a stress echo or stress MIBI has made this an unlikely cause.

If the patient develops further ischaemic sounding chest pain prior to these investigations, they should be reviewed urgently and considered for re-assessment that day in an emergency department or by a cardiologist.

copy and paste one from each of these conditions

aortic dissection rule out

low risk patient with no risk features

Aortic dissection is extremely unlikely in this patient as there are no risk factors such as hypertension, known aortic valvular abnormalities such as bicuspid valve, connective tissue disorders such as Marfans, no known vasculitic condition, no known polycystic kidneys, is not chronically immunosuppressed, no recent stimulant use such as cocaine, no mechanical precipitant such as heavy weight lifting, and no recent aortic surgery or intervention such as angiography, and the character of the pain is not suggestive of dissection, nor does the patient have significantly differences in BP between each arm, nor a widened mediastinum on CXR. In addition, the patient is NOT pregnant.

low risk patient with PH hypertension

Aortic dissection is extremely unlikely in this patient as although there is a PH of hypertension, there are no other risk factors such as known aortic valvular abnormalities such as bicuspid valve, connective tissue disorders such as Marfans, no known vasculitic condition, no known polycystic kidneys, is not chronically immunosuppressed, no recent stimulant use such as cocaine, no mechanical precipitant such as heavy weight lifting, and no recent aortic surgery or intervention such as angiography, and the character of the pain is not suggestive of dissection, nor does the patient have significantly differences in BP between each arm, nor a widened mediastinum on CXR. A negative D-Dimer further lowered the probability of dissection.

negative CT aortogram

As the patient had some features suggestive of aortic dissection, such as …….., a CT aortogram was performed. Fortunately there was no evidence of an acute aortic syndrome such as dissection on this study, and this makes aortic dissection very unlikely as a cause of this patient's presentation.

pulmonary embolism

negative PERC

Pulmonary embolism was considered as a cause but given the patient has a negative PERC score and a low probability gestalt for PE, it was decided against further investigation of PE at this stage as the pre-test probability of PE is too low to justify this and would risk a high probability that any positive scan result would be a false result and expose the patient to the risks of anticoagulation unnecessarily.

low probability with negative D-Dimer

Pulmonary embolism was considered as a cause but given the patient has a low probability gestalt for PE and a negative D-Dimer, it was decided against further investigation of PE at this stage as the pre-test probability of PE is too low to justify this and would risk a high probability that any positive scan result would be a false result and expose the patient to the risks of anticoagulation unnecessarily.

negative lung scan

Pulmonary embolism was considered as a cause as the pre-test probability for PE was sufficiently high to justify a scan to rule out PE. The scan was negative for PE which makes a significant PE at this time very unlikely.

pulmonary causes

There was no evidence of a pulmonary cause for the chest pain such as pneumothorax or pneumonia as neither were visualised on the CXR. This of course does not exclude early pathology or conditions such as pleurisy.

acute coronary syndrome

negative ECG and serial troponins

The patient was investigated for acute coronary sydrome but as there was no evidence of ST elevation, no evidence of Wellen's syndrome, nor dynamic changes on ECG suggestive of this, the gestalt was not of high probability for ACS, the pain resolved or was more likely to be caused by other conditions, and serial troponins were negative, it was deemed safe for the patient to be further investigated as an outpatient with a stress MIBI or stress echo. Could you please follow this up.

combined summary for the patient with no abnormalities found, no HT, PERC neg

No definitive cause for this patient's chest pain was found at this presentation. In particular, there was no evidence to support diagnoses such as aortic dissection, pulmonary embolism, acute coronary syndrome warranting emergent angiography, pericarditis, pneumonia, pneumothorax, shingles, or extra-thoracic causes such as biliary colic.

Aortic dissection is extremely unlikely in this patient as there are no risk factors such as hypertension, known aortic valvular abnormalities such as bicuspid valve, connective tissue disorders such as Marfans, no known vasculitic condition, no known polycystic kidneys, is not chronically immunosuppressed, no recent stimulant use such as cocaine, no mechanical precipitant such as heavy weight lifting, and no recent aortic surgery or intervention such as angiography, and the character of the pain is not suggestive of dissection, nor does the patient have significantly differences in BP between each arm, nor a widened mediastinum on CXR. In addition, the patient is NOT pregnant.

Pulmonary embolism was considered as a cause but given the patient has a negative PERC score and a low probability gestalt for PE, it was decided against further investigation of PE at this stage as the pre-test probability of PE is too low to justify this and would risk a high probability that any positive scan result would be a false result and expose the patient to the risks of anticoagulation unnecessarily.

There was no evidence of a pulmonary cause for the chest pain such as pneumothorax or pneumonia as neither were visualised on the CXR. This of course does not exclude early pathology or conditions such as pleurisy.

The patient was investigated for acute coronary sydrome but as there was no evidence of ST elevation, no evidence of Wellen's syndrome, nor dynamic changes on ECG suggestive of this, the gestalt was not of high probability for ACS, the pain resolved or was more likely to be caused by other conditions, and serial troponins were negative, it was deemed safe for the patient to be further investigated as an outpatient with a stress MIBI or stress echo. Could you please follow this up.

Despite the above, the patient should be further reassessed if their condition changes to ensure there is no delayed evidence to support any of the above, or other conditions which may become apparent with time.

In the interim, the patient has been advised to take regular aspirin 100mg daily, avoid exertion until further investigation of ischaemic heart disease such as a stress echo or stress MIBI has made this an unlikely cause.

If the patient develops further ischaemic sounding chest pain prior to these investigations, they should be reviewed urgently and considered for re-assessment that day in an emergency department or by a cardiologist.

chestpain_notation.txt · Last modified: 2015/04/13 17:00 (external edit)