Clinical Decision Tree
| Name of Patient | John Adams (not real name) | |||||
| Sex | Male | |||||
| Age | 58 | |||||
| Complaint | Chest Pain | |||||
| Faculty Chosen Diagnoses | Angina | Pericarditis | Myocardial Infarction | |||
| History of Present Illness (HPI) | Location | Localized to the breast bone; never radiates. | At the middle of the chest; also pain on shoulders. | Mainly localized to the chest, the back, neck region, and jaw bones | ||
| Quality | Burning sensation around the chest area | Pleuritic pain characterized by sharp and stabbing pain. | Acute chest pains in form of burning sensation | |||
| Quantity | Conditions last for about 5-15 minutes | Lasts from days to weeks. | Lasts between 30 to 60 minutes. | |||
| Chronology | Started a month ago; has become sharp for the last one week. | Began three months ago; from bad to worse. | Started six months age; condition has been worsening with time. | |||
| Setting | Occurs when the patient is engaged in physical activities such as playing soccer and dancing; Common at night when the patient lies down. | Severity of pain depends on one’s physical movements and activities; common among persons with traumatic injuries, kidney failure, and other conditions. | Common among people with family history for the condition, the aged, those who smoke, obese persons, and those who have high blood pressure. | |||
| Aggravating and alleviating factors | Physical activity aggravates the pains; rest helps to relieve the condition. | Condition becomes worse when one is lying flat, swallowing food, and breathing; learning forward can make one feel relieved. | Involvement in physical activities aggravates the condition; good rest can help to relieve pain. | |||
| Associated manifestations | Shortness of breath (SOB); no symptoms of nausea and sweating. | Coughing, SOB, fever, night sweats; no symptoms of swelling on the feet and ankles. | Fatigue, SOB, dizziness and sweating; no signs of vomiting and nausea. | |||
| Review of Systems (ROS) | Injury/trauma | Tackled by another player during a football match | Sustained minor injuries in a motor vehicle accident | No sign for trauma or injuries | ||
| Heart beat | Slightly abnormal heart beat | Abnormal heart beat | Abnormal heart beats | |||
| Dizziness | Feels dizzy | Feels very dizzy | Feels dizzy | |||
| Fever | No signs. | High fever | High fever | |||
| Nausea/vomiting | No symptoms. | No nausea and vomiting symptoms. | No observable symptoms | |||
| Recent travel history | Not travelled recently. | Travelled to a city recently. | No travel history | |||
| History of recent infections | Had a running nose one week ago. | Had a common cold recently | Developed common cold last week | |||
| Physical Examination (PE) | General appearance | Anxious but not distressed. | Highly distressed. | Is anxious | ||
| Vital signs | Body temperature: 37 °C; pulse: 102 per minute; Blood pressure (162/93 for right arm, 161/90 for left arm); height: Height 5’6″; weight: 78.8 kg; respiratory rate: 17 per minute | Body temperature: 38 °C; heart rate: 110; Blood pressure: 140/80; respiratory rate; 18 per minute. | Body temperature: 38 °C; heart rate: 112; Blood pressure: 160/100; respiratory rate; 18 per minute. | |||
| Skin condition | Normal appearance and texture | In good condition | Normal skin condition | |||
| Neck | Flexible and movable without any resistance | Supple neck that moves freely | Neck not flexible; experiences pain when turning sideways. | |||
| Cardiovascular system | Heart rate not normal; no murmurs | No rhythmic heart beats; extra beats; apical has hypertrophic cardiomyopathy; no sign of murmurs and other sounds. | Fast heart beats; Murmurs detected. | |||
| Abdomen | Has symmetrical abdomen without any form of distention; normal bowel sounds. | Flat and soft abdomen; Bowel sounds detected. | Flat abdomen; no bowel sounds. | |||
| Chest | Lungs are clear to auscultation and percussion; cystic changes notable on the affected breast region. | Diaphragm moving well; no percussion dullness. | Cystic changes observed on the affected part of the chest; clear lungs. | |||
| Extremities | No signs of peripheral edema | No signs for edema and cyanosis. | No signs of edema and clubbing | |||
| Pertinent Positives | General | Patient appears to be well; alert. | Patient looks normal. | Patient is well and collaborative. | ||
| HEENT | Has normal scalp; no rhinitis; normal conjunctiva and sclera; normal tympanic membrane; normal pharynx without exudate. | Scalp is normal; clear conjunctiva, and equal and round pupils; no obstruction in the nose; tympanic membranes are normal; no sign of exudates in the pharynx. | Normal scalp; pupils that are round and equal; normal tympanic membranes, normal nasal mucosa; pharynx is normal. | |||
| Cervical lymphadenopathy | Normal cervical lymph nodes. | Cervical lymph nodes are normal | Very normal cervical lymph nodes. | |||
| Other characteristics | Skin in good condition; supple neck. | Neck is flexible; normal respiratory rate. | Normal skin condition; normal respiratory rate. | |||
| Pertinent Negatives | Cardiac system | Palpation of the left chest leads to chest pains. | Palpation at the middle of the chest causes pains. | Palpation of the chest, neck, and the back causes pains. | ||
| Respiratory system | There is SOB (dyspnea). | Experiences SOB | SOB experienced | |||
| HEENT | Abnormal PERRL since pupils are no equal; less moist and mucous oral cavity membranes. | Discharge from the nose; dry oral cavity membrane. | Oral cavity membrane is dry; normal PERRL due to equality of pupils | |||
| Other features | Heartburns; fatigue. | Dizziness; fever | Fever; fatigue | |||
| Differentials | Acute myocardial infection; acute pericarditis; pneumonia. | Angina; acute myocardial infarction; aortic dissection; pneumonia | Angina; pericarditis; aortic stenosis; pulmonary embolism; pneumonia | |||
| Diagnostic Tool(s) Plan, Education, and Follow up | Diagnostic Plan | Analyzing results of HPI, ROS, and PE | Using ROS, HPI, and PE results. | Use of PE HPI, and ROS outcomes | ||
| Confirmatory tests | Coronary angiogram; exercise stress test, and electrocardiogram to rule out pericarditis and myocardial Infarction | Testing for pericardial rub using stethoscope; blood tests. | Laboratory tests; electrocardiography; cardiac imaging | |||
| Diagnostic test | Echocardiography, Magnetic resonance (MR) imaging, and coronary computed tomography | Echocardiogram; cardiac magnetic resonance imaging (MRI) | Cardiac CT or MRI; Echocardiogram | |||
| Final diagnosis | Chest x-ray; cardiac; computed tomography; electrocardiogram (ECG). | Electrocardiogram (ECG); chest x-ray | Echocardiogram; chest x-ray; coronary catheterization | |||
| Treatment plan | Asprin; nitroglycerin; ranolazine. | Pain relievers such as aspirin; colchicines; pericardiocentesis. | Antihyperlipidemics; beta-blockers; IV (intravenous) therapy; fibrinolytic therapy. | |||
| Patient education | Education on lifestyle changes; should take diet with low contents of saturated fat; should reduce the speed of physical activity. | Education on the importance f patient rest; advice on avoidance of strenuous physical activities. | Education on leading healthy lifestyles, such as taking fat that does not have excessive saturated fat. | |||
| Follow up | A close follow up by a primary care provider; monitoring changes in the intensity and frequency of angina. | Case to be closely followed up by primary care giver; monitoring the pattern of patient pain. | Close follow up by a primary care practitioner; closely monitoring frequency of heart attacks | |||
(Albarran & Tagney, 2007; Millikan & Saclarides, 2013; Chapman et al., 2017; Welch, 2019; Rahman et al., 2019).
References:
Albarran, J. W. & Tagney, J. (2007). Chest pain: Advanced assessment and management skills. Oxford, UK: Blackwell Pub.
Chapman, A. R., Shah, A. S. V., Lee, K. K., Anand, A., Francis, O., Adamson, P., McAllister, D. A., Strachan, F. E., Newby, D. E. & Mills, N. L. (2017). Long-Term Outcomes in Patients With Type 2 Myocardial Infarction and Myocardial Injury. Circulation, 137: 1236–1245
Millikan, K. W. & Saclarides, T. J. (2013). Common Surgical Diseases: An Algorithmic Approach to Problem Solving. New York, NY: Springer New York.
Rahman, H., Corcoran, D., Aetesam-ur-Rahman, M., Hoole, S. P., Berry, C. & Perera, D. (2019). Diagnosis of patients with angina and non-obstructive coronary disease in the catheter laboratory. Heart, 105: 1536–1542. 10.1136/heartjnl-2019-315042
Welch, T. D. (2019). Constrictive pericarditis: diagnosis, management and clinical outcomes. Heart, 104 (9). http://dx.doi.org/10.1136/heartjnl-2017-311683
