This clinical mind map is different in some ways because it is organized based upon the origin of chest pain from different systems, as opposed to the duration or location, which is the case in most other pain-related clinical mind maps. The reason for this departure from the standard organization is twofold. 1) Most practitioners find it easier to memorize causes of chest pain when these causes are broken down by systems. 2) Often times, causes arising from the same system produce similar characteristics of symptoms. For example, pain arising from cardiovascular causes is often exertion related and associated with shortness of breath, pain arising from pulmonary causes is typically pleuritic (although it is also associated with shortness of breath), and pain arising from gastrointestinal causes is typically postprandial. For this reason, a clinician can ask only a few questions early on in the evaluation process, and then determine which system and set of differentials are the most likely origin of a patient’s pain.
In order to address urgent/emergent situations, not only are the vital signs and the patient’s appearance reviewed, but the famous OPQRST set of questions is also asked. This is because OPQRST questions help determine the likelihood of ischemic chest pain, which can be life-threatening. Often patients with cardiac ischemia have normal vital signs, and quite frequently they appear to be at varying degrees of distress levels. Therefore, doing a quick OPQRST questionnaire helps address urgent/emergent situation. OPQRST questions are also listed as medium yield questions under “weighing and removing anchor bias,” so that even if these questions are not asked in the beginning, they are asked at some point in the evaluation process.
Additional medium yield questions include not only questions about features that are specific to certain conditions, but also about risk factors that substantially increase or decrease the likelihood of certain pathologies. Often questions about risk factors are asked in the process of history taking when past medical history is being explored. There is a tendency of “boxing” these set of questions, and asking them in an automated order, such as starting with the present illness to past illnesses, medications, family history, and social history. Although a good practice from a thoroughness and comprehensiveness standpoint, this practice inevitably leads to situations when certain components of the patient’s history are omitted due to the lack of time or the lack of a deliberate thought process about working through the differentials. This omission may pose a risk to diagnostic success. Therefore, in the case of chest pain, a deliberate attempt must be made to ask questions about risk factors when applicable (these can be a part of past medical history, drug use, recent infections/hospitalizations, or a variety of other components of history) without regard to what section of history is being explored. A physical exam and labs help establish the diagnosis. Some of the confirmatory tests include response to treatment instead of labs or imaging.