Chest Pain Evaluation Date Start time Stop time MRN

Allergies Chief complaint/Reason for consult

‰Allergy List Reviewed
Medications History of present illness
‰Medication List Reviewed
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Chest pain rated as ‰1 ‰2 ‰3 ‰4 ‰5 ‰6 ‰7 ‰8 ‰9 ‰10 Accompanying symptoms
Nature ‰Sharp ‰Dull ‰Pressure ‰Tearing ‰Orthopnea or PND
Duration (in minutes) ‰<1 ‰1-5 ‰6-10 ‰11-20 ‰21-60 ‰>1 hour ‰Dyspnea, wheezing or cough present
Radiation to ‰Left Arm ‰Right Arm ‰Neck ‰Jaw ‰Back ‰Peripheral edema
Frequency is ‰Stable over past 1 month ‰Profound fatigue
www.e-medtools.com
‰Increased in duration, nature or frequency ‰Diaphoresis
‰Occurs or increases with exertion ‰Palpitations, Dizziness or Syncope
‰Decreases with rest ‰Decreased appetite
Patient has received recent trauma ‰Yes ‰No ‰Leg pain or claudication
‰Recent use of medicines for erectile dysfunction ‰History of aortic aneurysm (Consider aortic dissection)
‰Recent severe emesis or www.e-medtools.com
esophageal dilatation ‰Strenuous resistance exercise (Consider aortic dissection)
Social History Review of Systems
‰Tobacco use

‰Packs x ‰Yrs ‰Quit See HPI WNL

‰‰ Constitutional Fatigue, malaise, fever/chills, weight loss, change in appetite

Occupational History
Daily, occasional and ex-smokers are
more likely to be hazardous drinkers ‰‰ Eyes www.e-medtools.com
Vision changes, New pain, Scotomas
‰ Alcohol use ‰‰ ENT/mouth Nose bleeds, dental caries, dental abscesses, jaw pain
‰‰
‰Drinks per ‰day ‰week
Resp Dyspnea, Cough, Phlegm, Hemoptysis, Wheeze, Witnessed Apnea
‰‰ CV Chest pain, diaphoresis, ankle edema, PND, syncope
Hazardous drinking ‰‰ GI Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena
NIAAA (National Institute on ‰‰ GU Change in urinary habits, hematuria, dysuria
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Alcoholism and Alcohol Abuse ‰‰ Musc Myalgias, recent trauma, bony fractures, arthralgias, joint swelling
guidelines)
Men > 14 drinks per week OR ‰‰ Skin/breasts Rashes, new masses or skin lesions, increased sensitivity to sun
> 4 drinks per day ‰‰ Neuro Seizures, episodic or chronic muscle weakness
Women > 7 drinks per week OR ‰‰ Endo Hair loss, polydipsia
>3 drinks per day ‰‰ Heme/lymph Bleeding gums, unusual bruising, swollen lymph nodes
‰Recreational drug use ‰‰ Allergy/Immun Sinus probs, recurrent infections
‰Inhalation ‰Injectable ‰Ingestible ‰‰ Psych Mood changes, agitation, psychosis, delirium, dementia
‰Drug dependence
‰Narcotics ‰Benzodiazepines

Family Medical History Past Medical and Surgical History

‰ Asthma ‰ Asthma ‰ Cerebral Artery Disease ‰ Neuromuscular weakness ‰ Chemotherapy Surgeries
‰ Congestive Heart Failure
‰ COPD ‰ Bronchiectasis ‰ Congestive Heart Failure ‰ Occupational exposures ‰ Colonoscopy
‰ Coronary Artery Disease ‰ COPD ‰ Coronary Artery Disease ‰ Pancreatitis ‰ ECHO/Stress Test
‰ Premature Onset ‰ COP (BOOP) ‰ Diabetes ‰ Peripheral Artery Disease ‰ Mammogram
‰ Diabetes ‰ Cystic Fibrosis ‰ GERD ‰ Scleroderma ‰ PFTs
‰ Malignancy ‰ Histiocytosis ‰ Hepatic Dysfunction ‰ Seizure Disorder ‰ PapSmear
‰ Pancreatitis ‰ Tuberculosis ‰ HIV/AIDS ‰ Sjogren ‰ Prior Intubations
‰ Peripheral Vascular Disease ‰ PAH ‰ Hypertension ‰ Renal Dysfunction ‰ Radiation exposure
‰ Renal Dysfunction ‰ Sarcoidosis ‰ Inflam bowel disease ‰ Rheumatoid arthritis ‰ Sleep Study
‰ Thyroid Disease ‰ Tuberculosis ‰ Malignancy ‰ Thrombotic Disease ‰ Steroid use
‰ Obstructive Sleep Apnea ‰ Thyroid Disease
‰ CPAP ‰ BiPAP

©MB and RR 2006, 2007 Revised 20Sep07

œIndicates reminders for 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
The number following the œ indicates the quality measure.
Chest Pain Evaluation Date Start time Stop time MRN
Vitals Exam ‰Checked box indicates findings are within normal limits
✔

Weight Const ‰General + 3 vital signs

BMI Eye ‰Conjunctivae ‰Pupils ‰Discs
ENT ‰TM ‰Pharynx ‰Dentition ‰Nasal ‰External ears ‰Hearing
Temperature
Neck ‰Exam ‰Thyroidwww.e-medtools.com
‰Jugular venous distention absent
BP
Resp ‰Auscultation ‰Effort
Sitting
CV ‰Ausc ‰Palp ‰Edema ‰Carotids ‰Abdominal Aorta ‰Femoral pulses ‰ Pedal pulses + 2 BPs
Lying
GI ‰Abdomen ‰No hepatosplenomegaly ‰No hernias ‰Rectum ‰Guaiac
Standing Lymph ‰Neck ‰Axilla ‰ Groin ‰Other
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Pulse
Musc ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength
Skin ‰Inspection ‰Palpation
Neuro ‰CN ‰DTR ‰Sensation
Respiratory Rate

Sats Psych ‰Affect ‰Orientation ‰Insight ‰ Memory

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Labs/Tests Impression and Plan
‰CXR (PA & lateral) Increased risk factors
‰CT of chest ‰Elevated troponin
(PE protocol if PE suspected)
‰12 lead ECG ‰High risk stress test www.e-medtools.com
‰ECHO ‰ECHO with EF of </= 0.4
‰Cardiac Enzymes ‰MI in past 6 months
‰Troponin ‰Prior CABG
‰Lipid panel ‰Hemodynamic instability
‰BNP ‰Ventricular tachycardia www.e-medtools.com
‰TSH ‰ST segment depression (ECG)
‰D-dimer
‰Resting pain >20 minutes
‰CBC
‰CMP ‰Age > 65 years
‰Hgb A1C www.e-medtools.com
‰CRP
‰Urine toxicology

Interventions
‰Beta-blocker
‰ACE Inhibitor
‰Statin
‰Antiplatelet agent
‰Nitrates
‰Morphine
‰Heparin or LMWH
‰Cardiac diet Signature 
CODE STATUS ‰Patient is a FULL CODE ‰DNAR DO NOT ATTEMPT RESUSCITATION
‰Smoking cessation counseling
‰ Patient has completed advanced health care directivesœ47
 HCPOA is

Data Reviewed ‰ER Notes ‰Old Chart ‰Nursing Notes & Vitals log ‰Labs ‰Radiology data ‰ECHO ‰ECG ‰Stress Test ‰PFT ‰Diabetic log
Coordination of care ‰ED MD ‰HCPOA ‰PCP ‰Case Mgmt ‰SW ‰Pharmacy ‰Nutrition team ‰Physical therapy ‰Respiratory therapy ‰Nursing
©MB and RR 2006, 2007 Revised 20Sep07
œIndicates reminders for 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
The number following the œ indicates the quality measure.