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What is the Most Important Factor in Evaluating Chest Pain

Physician Assistant
By John Bielinski, MS, PA-C





If you know John, you have learned about “Who’s Your PAPPA” and the 5 can’t miss causes of chest pain. But my question to you is: What’s the most important factor in evaluating someone with chest pain?

Is it the EKG? No.
Is it enzymes? No.

It is history.


For any person right now, if you gave me a good enough story, I could get you admitted with chest pain. It is all about the story. You want to size them up for risk factors. You are going to watch out for these people. You are going to watch out and think of risk factors. You can’t assess chest pain without risk factors. An EKG is very helpful. A normal EKG is nice, but it is not diagnostic. I have seen lots and lots and lots of people who were very, very sick who had normal 12-leads.

For newer providers, I am going to give you a mnemonic. This will be helpful in gaining a history of present illness.
Now in order for this to work, you will have to remember that I am from Buffalo, NY, and in Buffalo it gets COLDER FAST.

C – Character- “Sir, can you describe the pain? How bad is it? Is it sharp? Dull? Crampy?
O – Onset – When did it first come on?
L – Location – Can you point to it?
D – Duration – How long have you had it?
E – Exacerbation – Does anything make it worse?
R – Remedies – Does anything make it better?
F – Frequency – How often do you get it?
A – Associated Symptoms – Have you had this before?
S – Same Symptoms in the Past- Again, Have you had this?
T – Treatment in the past- How have they treated you in the past?

Remember it is your duty to your patients to make sure that if they leave the ER after seeing you, that they will not go home and die. Always ask chest pain patients, “Who’s your PAPPA” and make sure to get a detailed history to properly evaluate their pain.

Learn more at a Skin Bones CME Conference.