Trainee Advanced Clinical Practitioner Diary- Day 12 - Critical Care Practitioner

Trainee Advanced Clinical Practitioner Diary- Day 12

Respiratory and chest pain history taking- key points. Tutorial with two of the Emergency Department consultants.

Treat chest pain as ischeamic heart disease until proven otherwise. Try to discover features of the chest pain which might lead you to a different conclusion.

Differentials might include:


Pulmonary Embolism





Has the patient had the pain before?

How long did they have the pain for?

What brought the pain on- do they get it at rest or with exertion?

Does the patient have any of the risk factors?


  • Age >= 65- Aspirin use in the last 7 days (patient experiences chest pain despite ASA use in past 7 days)- At least 2 angina episodes within the last 24hrs- ST changes of at least 0.5mm on admission EKG- Elevated serum cardiac biomarkers- Known Coronary Artery Disease (CAD) (coronary stenosis >= 50%)

    – At least 3 risk factors for CAD, such as:


Hypertension -> 140/90 or on antihypertensives,

current cigarette smoker,

low HDL cholesterol (< 40 mg/dL),

diabetes mellitus,

Family history of premature CAD (CAD in male first-degree relative, or father less than 55, or female first-degree relative or mother less than 65).

The TIMI Risk Score for Unstable Angina/Non–ST Elevation MIA Method for Prognostication and Therapeutic Decision Making- JAMA. 2000;284(7)

Risk factors for myocardial infarction in women and men: insights from the INTERHEART study- European Heart Journal 2008.

Cardiovascular risk factors and clinical presentation in acute coronary syndromes- Heart 2005;91:1141–1147

GRACE ACS Risk and Mortality Calculator


Common respiratory conditions:

  • Pulmonary Embolism
    • Risk factors (Wells, PERC)
      • Clinical signs and symptoms of a DVT
      • PE is #1 diagnosis or equally likely
      • Heart rate > 100
      • Immobilisation at least 3 days or surgery in last 4 weeks
      • Previous diagnosis of PE or DVT
      • Haemoptysis
      • Malignancy with treatment or palliative
    • Chest pain, sharp, pleuritic
    • Haemoptysis
    • Calf pain.
  • Asthma
    • Questions
      • Meds with spacer?
      • Triggers/exercise/drugs
      • PMHx
      • Timing (commonly night/early morning as cortisone levels drop)
      • FHx- atopic (asthma, eczema, hay fever)
      • Last asthma attack
      • ITU admissions/ventilator
      • Steroid use
      • Usual severity- different this time?
  • COPD
    • Questions
      • LTOT
      • Normal function
      • Increased sputum
      • Nebulisers
      • ITU admissions/NIV
      • Steroid therapy
      • ?Anxiety
      • Changes in medication.
  • LRTI/Pneumonia
    • Headache
    • Malaise
    • Cough-sputum
    • Chest pain
    • Haemoptysis
    • Imm compromised

Respiratory History Taking- Geeky medics.

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