Knowledge - Students should be able to describe and define:

1. Signs and symptoms associated with the common causes of chest pain which include the following:
   1. Cardiac:
      -Coronary artery disease (ischemic):
              Angina (typical, atypical)
              Variant angina
              Acute myocardial infarction
      -Valvular:
              Aortic stenosis
              Mitral valve prolapse
      -Cardiomyopathy:
              Hypertrophic
      -Pericarditis
   2. Vascular (noncardiac):
              Aortic dissection
              Pulmonary embolus
              Pulmonary hypertension
   3. Pulmonary:
              Pneumonia/pleurisy
              Tracheobronchitis
              Pneumothorax
              Tumor
   4. Gastrointestinal:
              GERD
              Esophageal spasm
              Mallory-Weiss tear
              Peptic ulcer disease
              Biliary tract disease
              Pancreatitis
   5. Musculoskeletal:
              Costochondritis
              Muscular
   6. Miscellaneous:
              Chest wall tumor
              Herpes zoster (dermatomal)
              Emotional

2. The basic pathophysiology of the following causes of chest pain:
   1. Ischemic chest pain:
          Stable angina
          Unstable angina
          Acute MI
   2. Pericarditis
   3. Aortic dissection
   4. Pulmonary embolus
   5. Esophageal pain

3. Risk factors for the various causes of chest pain, especially:
   1. Cardiovascular risk factors (see Chapter 244, page 1366)
   2. Risk factors for venous thromboembolism
          Virchow's Triad
          Stressors (see Table 261-1, page 1469)

4. Applications of the principles of clinical reasoning in the assessment of the patient with chest pain.
   1. How the historical and physical exam data can be used to develop a differential diagnosis in an individual patient, rank these diagnostic possibilities and assign approximate percent probabilities to them.
   2. Integration of clinical data and test results.
   3. Understand the use of pre-test probability of CAD in the interpretation of the results of exercise stress tests.
   4. Familiarity with empirically derived algorithms (practice guidelines) with LUMC as example (when available).

Skills - Students should be able to:

1. History-taking: obtain, document and present a medical history that differentiates among the various causes of chest pain. Determine and describe any cardiac risk factors, as well as those for venous thrombosis.
   
   
2. Physical examination: perform a physical exam to establish the diagnosis of a patient with chest pain which would include: blood pressure (both arms, orthostatic changes); pulses, presence of bruits; fundus (vascular changes of atherosclerosis); extremities: edema, clubbing, cyanosis, temperature; lungs: rales, rhonchi, wheezing, breath sounds, signs of consolidation and effusion; inspection/palpation of the chest for heaves or thrills; examination of the heart for rhythm, murmurs (systolic: ejection, regurgitant; diastolic), rub, gallops, extra sounds (clicks, gallops), heart sounds (intensity [8 P2] splitting [physiologic, abnormal]); examination of the abdomen for tenderness (epigastrium, RUQ), hepatomegaly; examination for lymphadenopathy. Thoroughly evaluate the musculoskeletal system for cervical disk disease, arthritis of shoulder, costochondritis.
   
   
3. Differential Diagnosis: generate a differential diagnosis that recognizes specific history and physical exam findings that distinguish cardiac, vascular, pulmonary, GI (Figure 13.2).
   
   
4. Laboratory: interpret triage patients based on the ECG (Figure 13.3), cardiac enzymes (acute myocardial infarction), chest x-ray (pneumonia/pleurisy, aortic dissection, pneumothorax, malignancy), arterial blood gases (hypoxia, hyperventilation), CBC (anemia, infection). Define the indications and interpret the significance of the results of the following:

Echocardiogram - 2D, Doppler
Stress test:
  - with myocardial perfusion imaging
  - with echocardiography
  - exercise versus pharmacologic
Cardiac catheterization
Pulmonary V/Q scan
Pulmonary angiogram
Ultrafast coronary CT

5. Communication: communicate the diagnosis, treatment plan and prognosis of the disease to patients and families.
   
   
6. Procedural: electrocardiogram.
   
   
7. Management: Students should be familiar at an introductory level with treatment of the following:

Stable angina
   - Beta Blockers
   - Calcium Blockers
   - Nitrates
Unstable angina
  - ASA
  - Anticoagulation
  - Antiplatelet therapy
Acute MI
  - Primary Angioplasty
  - Fibrinolytic therapy
  - CABG Pericarditis
  - Non-Steroidal Anti-inflammatory
  - Steroids
  - Uremia induced-dialysis
Pulmonary Embolism
  - Anticoagulation
  - Fibrinolytic

Access and utilize information systems and resources to help delineate issues related to chest pain.

Attitudes and Professional Behaviors:

• Students should be able to understand the emotional impact of a diagnosis of CAD and DVT and its potential effect on lifestyle.

Required Readings:

1. Goldman L, Braunwald E, Chest Discomfort, Chapter 12, in Harrison's Principles of Internal Medicine, 14th ed. Fauci AS et al eds. 1998, McGraw-Hill, New York, pp 58-64.
2. Antman E, Braunwald E, Acute Myocardial Infarction, Chapter 243, in Harrison's Principles of Internal Medicine, 14th ed. Fauci AS et al eds. 1998, McGraw-Hill, New York, pp 1352-1365.
3. Selwyn AP, Braunwald E, Ischemic Heart Disease, Chapter 244, in Harrison's Principles of Internal Medicine, 14th ed. Fauci AS et al eds. 1998, McGraw-Hill, New York, pp 1365-1375.
4. Goldhaber S, Pulmonary Thromboembolism, Chapter 261, in Harrison's Principles of Internal Medicine, 14th ed. Fauci AS et al eds. 1998, McGraw-Hill, New York, pp 1469-1472.

Suggested Readings:

1. Fuster V, Pearson T: 27th Bethesda Conference: Future Perspectives on Matching the Intensity of Risk Factor Management with the Hazard of Coronary Disease Events.

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