CC: CP - the Hx
First, does a history even help in determining the cause of undifferentiated CP?
By definition we are talking about undifferentiated CP, not CP caused by something obvious the patient told you, like “My chest hurts ever since it hit the steering wheel in a car crash.”
Remember OPQRST? Or SOCRATES?
I can’t, and I don’t know if “Did you call a lawyer?” fits in either of those, but I have heard patients say that their lawyer told them to go to the ER several days after an MVC, and it was quite informative.
But does the Hx matter in undifferentiated CP???
Of course it does!
Salim Rezaie, "Chest Pain: What is the Value of a Good History?", REBEL EM blog, November 1, 2013. Available at: https://rebelem.com/chest-pain-value-good-history/.
Because we are talking about undifferentiated CP, I am not going to include EVERYTHING a patient might say that could be a clue to the etiology of their symptoms. That list would be quite long and include things like “Do you have a knife in your chest?”
Narrowing in on identifying acute coronary syndrome (ACS), research has found there are some specific characteristics of the “HPI” that can increase or decrease the likelihood that a patient has ACS and/or AMI.
A history that includes CP PLUS radiation, diaphoresis, N/V, and/or exertion INCREASES the likelihood of ACS. Therefore, it is a great practice to include all these features in a thorough HPI.
Including the presence of pleuritic, positional, stabbing, or palpable pain, can decrease the likelihood of ACS in your routine HPI is also advisable as a way to prompt you to consider pericarditis, PE, GERD, pneumonia, MSK, or other etiologies
Please read the full article for context and remember that increasing or decreasing the likelihood of CP caused by ACS does NOT rule out the presence of AMI. Instead, you can use these clues to help you think of potential OTHER causes of CP.
“In the event of a missed diagnosis of myocardial infarction, thorough documentation of the absences of features most common in ACS is important. ”
But don’t stop there!!! Comprehensive documentation includes consideration for ALL potential dangerous or critical causes of CP.
The following list includes the Dx - followed by the pertinent hx and risk factors for many diseases that could present with CP. These can broadly be divided into cardiac ischemia and/or inflammation, pulmonary etiology, vascular, thoracic wall, and extra-thoracic etiologies
Cardiac ischemia/inflammation
ACS - CP with exertion, CP plus diaphoresis, similar to prior angina/MI, hx of HTN, DM, PAD, CAD.
Takotsubo cardiomyopathy - mimics ACS, sudden onset, emotional distress
Coronary vasospasm - cocaine use, family history
Pericarditis - CP worse lying, better sitting up, pleuritic pain, recent viral infection, prior pericarditis
SCAD - pregnant, connective tissue disease
Myocarditis - recent illness, sx of heart failure
Endocarditis - IVDU, fever, immunosuppressed
Thoracic vascular disease
Aortic dissection - sudden, tearing pain radiating to the back, Marfan or connective tissue disorder, age > 50, hx of HTN and/or PAD.
Thoracic aortic aneurysm - known history (does not usually present as CP)
Pulmonary
PE - pleuritic, hemoptysis, DOE, active cancer or clotting disorder
Pneumonia - fever, cough, pleuritic CP
Asthma/COPD - hx of either, SOB, chest wall pain, worse with deep inspiration
Pneumothorax - sudden, resolved pain, tall-thin, SOB
Mediastinum pathology
Mediastinitis - possible neck/dental source/pathology, Ludwig angina, sx of infection
Esophageal foreign body - occurs with swallowing, regurgitation/unable to swallow
Esophageal rupture - forceful vomiting
Extra-thoracic (abdominal) source
Esophageal/GERD/gastric ulcer - acid taste, occurs before/after eating
Gallbladder disease - post-prandial pain, RUQ pain, radiation to R shoulder
Pancreatitis - pain with eating, EtOH/gallstone associated
The problem that we run into again, is the sheer length of the above list and number of questions, clinical risk factors, and features that would need to be included. Here, I defer to your preferences in your documentation. I believe that it is easier and faster to DELETE unnecessary portions of an HPI that you did NOT ask, than it is to dictate ALL the portions that you did cover. PLUS, a long list of features and risk factors MAY even remind you to ask questions relevant to rare diseases.
Additionally, several commonly used clinical decision making tools use “suspicion,” historical features, and other risk factors to calculate risk scores. These include the HEART pathway, Well’s criteria for PE, and the PERC rule.
Outside of the VS, PE, and lab findings, you must remember to ask patients their history of DM, obesity, HTN, and hyperlipidemia, recent/current smoking status, family hx of CAD <65, prior MI/PCI/CAB, CVA/TIA, or PAD for the HEART pathway. For the PE scoring systems, you should ask about leg swelling, recent surgery or trauma, prior PE or DVT, cancer treatment within 6 months, hemoptysis, and hormone use including oral contraceptives and hormone replacement.
The question is - Can you create a “standard” HPI template that reminds you to ask all those questions?
Possible HPI documentation template:
Patient presents with chest pain for *** described as ***. There is *** radiation to ***. *** diaphoresis with pain. The pain is *** worse with exertion and is *** relieved with rest. There is *** pain with breathing or deep inspiration. The pain is *** with sitting; *** in pain with lying flat. *** recent fever or infectious symptoms. *** cough recently. Pain is *** associated with eating. *** leg or feet swelling.
The patient has *** known CAD. *** prior DVT or PE. There have been *** recent immobilizations or surgeries. *** unilateral leg or calf pain. The patient does *** take exogenous hormones or OCP. The patient *** smokes cigarettes. *** recent cocaine use. *** history of IVDU.
The end of the above HPI also includes the PMH and social history. It depends on your documentation style, if you want to include these in the HPI or elsewhere. Alternatively, you could add reminders to your template that include risk factors within the ROS, PMH, Family History, etc.
Expert tip: While many EHRs automatically import PMH, FH, and other aspects of patient history collected at triage or in prior visits, it is still possible to miss many risk factors that were not specifically asked about in prior visits. For example, a patient may have started taking contraceptive pills or had a recent surgery not automatically imported into the chart. It is best practice to review all information that is used in medical decision-making at the time of the visit, not relying on prior documentation that may not have addressed cocaine or illicit drug use.
Your template or documentation could also be broken up like this…
HISTORY OF PRESENT ILLNESS
Patient presents with chest pain for *** described as ***. There is *** radiation to ***. *** diaphoresis with pain. The pain is *** worse with exertion and is *** relieved with rest. There is *** pain with breathing or deep inspiration. The pain is *** with sitting; *** in pain with lying flat. *** recent fever or infectious symptoms. *** cough recently. Pain is *** associated with eating. *** leg or feet swelling. *** unilateral leg or calf pain.
PAST MEDICAL HISTORY
Reviewed for risk factors of prior CAD or MI, HTN, DM, PE or DVT, or other vasculopathy. *** history of cancer. *** history of VTE.
SURGICAL HISTORY
*** recent surgeries or immobilizations.
CURRENT MEDICATIONS
*** current oral contraceptive pill.
FAMILY HISTORY
*** history of premature heart disease or MI under the age of 55.
SOCIAL HISTORY
Reviewed for current or recent smoking, cocaine use, or IVDU.
REVIEW OF SYSTEMS
General: *** fever.
Neuro: *** recent syncope.
Skin: *** rash. *** lesions on hands or feet.
ENT: *** rhinorrhea or sore throat.
Neck: *** swelling or pain.
GI: *** nausea.
Extremities: *** lower extremity swelling.
Psych: *** anxiety. *** depression.
With recent changes in documentation requirements for coding and billing purposes, the details of your HPI and ROS are no longer necessary for higher-level billing. This means you no longer need to document a 10-point ROS or HPI with 4+ characteristics. That does not mean that you no longer need to collect this information.
To shorten your documentation, you may write “History and physical examination appropriate for complaint” but this does little to defend yourself in court when asked how thorough you were in your H&P during a patient visit several years ago, now being litigated. As I have said before, it is easier to delete what you did not do, than to dictate what you did ask. Beyond that, a template might even remind you to back into a room and ask the patient if they had recently used cocaine which could greatly change the treatment plan.
However, you document, consider both efficiency and accuracy when creating a template that can accurately reflect what you actually said and did during each individual patient visit.
