Sam speaks to Dr Adele Pope, advanced cardiology trainee at Auckland Hospital, about how to attack the most common, and often the most uncertain, ward call.

Differential

* Life threatening

* ACS

* PE

* Dissection

* Cardiac tamponade

* Pneumonia

* Pneumothorax

* Oesophageal bleed

* Heart

* Pericarditis

* Lungs

* Mechanical (foreign body, surgical, chest drain, post-pleurocentesis)

* Oesophagus

* Reflux

* Oesophagitis

* Oesophageal spasm

* MSK

* Musculoskeletal

* Costochondritis

* Rib fracture

* Below the chest

* Upper abdominal pain

* Above the chest

* Anxiety

Approach

* Eyeball the patient

* ABCs

* Calling a code

* 777 (or your local hospital emergency number)

* This is Sam, medical house officer. I need the adult resus team to attend North Shore Hospital, ward 10, room E3.

* History

* SOCRATES (site, onset, character, radiation, associated symptoms, timing, exacerbating factors, severity)

* Previous similar episodes? History of exertion chest pain?

* Diaphoresis

* Shortness of breath

* Review of systems

* Identify risk factors

* Vitals + Examination

* General inspection + peripheries

* Aiming to identify red flags of hypotension, reproducibility on palpation and respiratory issues

* Abdomen, calves, catheter and drains (for completeness)

*  ECG

* Take your time and be systematic

* Look at an old ECG

* Ischaemic ECG defined as STEMI, or any T wave inversion, ST depression, Q waves.

* Look for contiguous and reciprocal abnormalities.

* T wave change normal variants occur in III, aVR, V1.

* A repeat ECG in 15 minutes is useful to identify dynamic changes.

* Consider investigations

* FBC, U&E, troponin

* CXR if failure or respiratory issues are within your differential (not so useful for ACS, but unlikely to harm)

* Management

* Call for help (code or at least registrar support)

* Attach continuous monitoring e.g. defibrillator pads

* Re-assess stability of the patient

* Oxygen only if hypoxic

* GTN spray

* Opiate analgesia (IV morphine boluses ideally)

* Determine bleeding risk

* Identify any anti-platelet and anti-coagulation medicines in use

* Post-operative status

* Consider loading with aspirin 300 mg PO

* Document

* Review past notes

* Basics (date/time/name/reason for review)

* Positives and pertinent negatives

* Impression and differential with justification. Have you eliminated life threatening conditions?

* Consider TIMI or HEART score (acknowledging use outside of ED)

* Clear and specific plan

* Consider discussion with senior and escalation, especially if called back to patient again

Specificity of chest pain symptoms and examination findings [Evidence]

Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?The Rational Clinical Examination Systematic Review. JAMA. 2015;314(18):1955–1965. doi:10.1001/jama.2015.12735

* No single finding rules in or rules out acute coronary syndrome.

* The most specific (convincing) symptoms of ACS were:

* Pain radiation to both arms (specificity, 96%; LR, 2.6 [95% CI, 1.8-3.7]).