Chest Pain HISTORY_LIST ***** HISTORY OF PRESENT ILLNESS duration of pain location radiation character intensity rate of onset pain with activity relief by nitroclycerine relief by rest relief by antacids increased comsumption of nitroglycerine tablets increase in frequency of pain increase in severity of pain improvement of pain since onset worsening of pain since onset occurence during rest or sleep diaphoresis nausea vomiting dyspnea orthopnea doe edema leg pain weakness hemoptysis dysphagia cough sputum paresthia of arm, hand or face syncope exacerbation by inspiration cough position arm chest neck back movement eating anxiety sexual intercourse exacerbation by exposure to cold or heat exacerbation by aspirin nsaids, or cocaine ***** HISTORY CHRONIC DISEASE SYSTEMIC DISORDERS claudication diabetes exercise intolerence hx of a stroke pud melena abdominal pain bleeding risk factors hyperuricemia peripheral vascular disease premenopausal postmenopausal smoking PREVIOUS TESTS stress testing angiogram nuclear scan EGG FAMILY HISTORY family hx of coronary artery disease before age 55 diabetes HTN hypercholesterolemia MEDS_LAB_TESTS ***** MEDS nitroglycerine beta blockers heparin ASA calcium channel blockers ranitidine noncompliance with antihypertension medications bronchodilators amphetamines NSAIDS oral contraceptives antidepressants steroids tricyclics MAO inhibitors **** LAB CPK MB fraction LDH Mg CBC Electrolytes ***** TESTS R/O MI ECG ST elevation ( 0.1 mV in one, or more limb leads or, 1.5 - 2.0 mV in one or, more V lead T wave inversions) Horizontal ST segment depression of 1.0-2.0 mV in, both limb and precordal,leads (subencardial infarction) CXR shows cardiomegaly and pulmonary edema REVIEW_OF_SYSTEMS_1 GENERAL weight changes appetite changes anorexia difficulty sleeping fever chills polyphagia hypophagia changes in thirst sleeping habit change bowel habit change fatigue hypertension previous physical exams SKIN pigmentation changes texture changes lesions eruptions pruritis easy bruising easy bleeding unusual hair loss changes in hair distribution skin masses finger/toe nail change rashes hives striae skin atrophy uremic frost hirsutism plethora neurofibromatosis lesion HEENT head trauma skull fractures head masses hearing loss vertigo chronic ear infection ear discharge ear pain hearing aid use loss of vision recent change in vision photophobia diplopia (double vision) glaucoma exudates dry eyes eye pain cataracts eye surgery itchy eyes excessive tearing corrective lenses nose bleeds chronic sinusitis nasal fractures nasal drainage polyps changes in sense of smell edentulous (without teeth) partial plate full plate recent dental work oral lesions tonsillitis strep throat tongue problems voice changes chronic hoarseness chronic halitosis NECK neck masses enlarged thyroid gland brachial cleft cysts neck injury REVIEW_OF_SYSTEMS_2 CHEST chronic coughing sputum production hemoptysis wheezing pneumonia bronchitis TB TB exposure SOB (altered by position?) edema chest pains pacemaker HEART MI coronary artery disease heart murmur heart valve disease left ventricular hypertrophy mistral valve stenosis pericarditis palpitations DOE paroxysmal nocturnal dyspnea orthopnea edema hypertension rheumatic fever cardiomyopathy ectopic heart beats arrhythmia exercise intolerance claudication heart medications ABDOMEN abdominal pain nausea vomiting diarrhea constipation hematochezia hematemesis hemorrhoids GI x-rays GI scopings rectal bleeding ulcers bowel polyps bowel incontinence gall bladder disease gall stones hepatitis cirrhosis hepatomegaly splenomegaly GU renal insufficiency renal failure dialysis kidney stones kidney disease kidney cyst flank pain hematuria pyuria dysuria chronic cystitis nocturia anuria hesitancy enuresis change in urine color prostatitis epididymitis scrotal problems TURP pain on intercourse genital lesions genital discharge REVIEW_OF_SYSTEMS_3 OB/GYN metorrhagia menorrhagia irregular menses problems in pregnancy use of contraception breast masses nipple discharge breast skin changes changes in axillary nodes monthly breast exam breast feeding children EXTREMITIES difficulty with gait weakness joint swelling joint stiffness muscle pain muscle swelling muscle injuries agittal plan scoliosis coronal plane scoliosis fractured bones SLE osteoarthritis rheumatoid arthritis fibromyalgia NEURO seizures head injury LOC loss of coordination difficulty in balance sciatica difficulty in fine motor skills difficulty speaking CVA (stroke) weakness in arms weakness in legs tingling in legs and feet tingling in arms PSYCHIATRIC depression bipolar disorder suicide attempts hospitalization for, psychiatric problems personality disorders ENDOCRINE goiter exophthalmos dry skin dry hair intolerance to heat intolerance to cold changes in growth sterility impotence decreased libido LYMPHATIC AND HEMATOLOGICAL lymphadenopathy transfusion anemia PHYSICAL_EVAL_1 VITALS BP in both arms Postural BP Pulse Temp Heart rate GENERAL visible pain apprenhension respiratory distress pallor SKIN cold extremities xanthomas HEENT fundi silver wire arteries fundi arteriolar narrowing fundi A-V nicking hypertensive retinopathy carotid pulse amplitude carotid pulse duration PHYSICAL_EVAL_2 CHEST crackles wheezes percussion note friction rub HEART decreased intensity of S1 paradoxical splitting of S2 presence of S3 presence of S4 chest wall tenderness dyskinetic cardiac impulse enlarged apical impulse prolonged apical impulse displaced apical impulse Levine's sign (patient with clenched fist over sternum) ABDOMEN epigastric tenderness pulsatile mass hepatomegaly RECTAL occult bleeding EXTREMITIES edema extent of edema unequal pulses femoral bruitis deminished pulses calf pain and swelling xanthomas (lipid deposits over tendons) elevation pallor of legs and feet DIFF_DIAGNOSIS MI PE PUD Gastritis Aortic dissection Pericarditis Pleurisy Cardiomyopathy Esophagitis Espohageal,spasm,tear,rupture Mitral Valve Prolapse Pulmonary Hypertension Psychogenic pain Pneumothorax Musculskeletal chest wall pain Costrochondritis,(Tietze's syndrome) Osteoarthitis of the spine or shoulder Hiatal hernia Pancreatitis Cholycystits Bronchitis Pneumonia Pleuritis Malignancy Breast disease Intercostal neuritis (Zoster)