Clinical Decision Tree

Name of PatientJohn Adams (not real name)
SexMale
Age58
ComplaintChest Pain
Faculty Chosen DiagnosesAngina            PericarditisMyocardial Infarction
History of Present Illness (HPI)LocationLocalized 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 
QualityBurning sensation around the chest areaPleuritic pain characterized by sharp and stabbing pain.Acute chest pains in form of burning sensation
QuantityConditions last for about 5-15 minutesLasts from days to weeks.Lasts between 30 to 60 minutes.
ChronologyStarted 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.
SettingOccurs 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 factorsPhysical 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 manifestationsShortness 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/traumaTackled by another player during a football matchSustained minor injuries in a motor vehicle accidentNo sign for trauma or injuries
Heart beatSlightly abnormal heart beatAbnormal heart beatAbnormal heart beats
DizzinessFeels dizzy Feels very dizzyFeels dizzy
FeverNo signs.High feverHigh fever
Nausea/vomitingNo symptoms.No nausea and vomiting symptoms.No observable symptoms
Recent travel historyNot travelled recently.Travelled to a city recently.No travel history
History of recent infectionsHad a running nose one week ago.Had a common cold recentlyDeveloped common cold last week
Physical Examination (PE)  General appearanceAnxious but not distressed.Highly distressed.Is anxious
Vital signsBody 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 minuteBody 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 conditionNormal appearance and textureIn good conditionNormal skin condition
NeckFlexible and movable without any resistanceSupple neck that moves freelyNeck not flexible; experiences pain when turning sideways.
Cardiovascular systemHeart rate not normal; no murmursNo rhythmic heart beats; extra beats; apical has hypertrophic cardiomyopathy; no sign of murmurs and other sounds.Fast heart beats; Murmurs detected.
AbdomenHas symmetrical abdomen without any form of distention; normal bowel sounds.Flat and soft abdomen; Bowel sounds detected.Flat abdomen; no bowel sounds.
ChestLungs 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.
ExtremitiesNo signs of peripheral edemaNo signs for edema and cyanosis.No signs of edema and clubbing
Pertinent Positives    GeneralPatient appears to be well; alert.Patient looks normal.Patient is well and collaborative.
HEENTHas 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 lymphadenopathyNormal cervical lymph nodes.Cervical lymph nodes are normalVery normal cervical lymph nodes.
Other characteristicsSkin in good condition; supple neck.Neck is flexible; normal respiratory rate.Normal skin condition; normal respiratory rate.
  Pertinent Negatives  Cardiac systemPalpation 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 systemThere is SOB (dyspnea).Experiences SOBSOB experienced
HEENTAbnormal 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 featuresHeartburns; fatigue.Dizziness; feverFever; fatigue
Differentials    Acute myocardial infection; acute pericarditis; pneumonia. Angina; acute myocardial infarction; aortic dissection; pneumoniaAngina; pericarditis; aortic stenosis; pulmonary embolism; pneumonia
Diagnostic Tool(s) Plan, Education, and Follow up  Diagnostic PlanAnalyzing results of HPI, ROS, and PEUsing ROS, HPI, and PE results.Use of PE HPI, and ROS outcomes
Confirmatory testsCoronary angiogram; exercise stress test, and electrocardiogram to rule out pericarditis and myocardial InfarctionTesting for pericardial rub using stethoscope; blood tests.Laboratory tests; electrocardiography; cardiac imaging
Diagnostic testEchocardiography, Magnetic resonance (MR) imaging, and coronary computed tomography    Echocardiogram; cardiac magnetic resonance imaging (MRI)Cardiac  CT or MRI; Echocardiogram
Final diagnosisChest x-ray; cardiac; computed tomography; electrocardiogram (ECG).Electrocardiogram (ECG); chest x-rayEchocardiogram; chest x-ray; coronary catheterization
Treatment planAsprin; nitroglycerin; ranolazine.Pain relievers such as aspirin; colchicines; pericardiocentesis.Antihyperlipidemics; beta-blockers; IV (intravenous) therapy; fibrinolytic therapy.
Patient educationEducation 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 upA 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

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