Preceptor Pearls: Take CARE with Chest Pain

In our May blog post, we introduced you to the CARE acronym (Common, Atypical, Rare, Emergent) to help students formulate differential diagnosis. Over the next few months, we want to apply the CARE acronym to some chief complaints. We hope this will be helpful to you as you’re precepting students. Share this blog post and graphics with them during their next shift! 

One of the most daunting chief complaints for me as an FNP student was chest pain. As a CVICU nurse, chest pain was synonymous with an MI in my brain. During an urgent care rotation when I saw a lot of chest pain patients as a student, I struggled to broaden my differential diagnosis from what could kill this patient to more common, primary care complaints.

Here’s how using the CARE acronym helped me make this distinction:

• Not every patient with chest pain needs a full cardiac work-up and referral to the ED.  In fact, the most common cause of chest pain in patients presenting to primary care clinics is musculoskeletal in etiology.  Other common etiologies include GERD and anxiety. It’s important to keep those “can’t miss” chest pain diagnoses on your differential list and to rule them out with your history, physical exam, and possibly ancillary tests.
  
  
• My favorite atypical chest pain differential is herpes zoster. This sneaky viral rash can be the culprit of so many “fill in the blank body part” pain complaints including back, abdomen, chest, extremity! This is one of the reasons that I encourage the NP students I precept to inspect the skin overlying the painful area on any patient complaining of pain. 
  
  
• Pericarditis, myocarditis and cardiac tamponade can be considered on the differential list, but are more rare diagnosis for a chief complaint of chest pain. 
  
  
• These emergent diagnoses are commonly called “the big 5”: myocardial infarction, pulmonary embolism, thoracic aortic dissection, pneumothorax, and esophageal rupture.

What other differentials do you think of when you see a chief complaint of chest pain on your clinic schedule? What is your favorite atypical chest pain diagnosis? 

We’d love to hear your thoughts! Leave us a comment (UC RAP > August 2023 > Chapter 5 > Discussion) and join us in discussing this important topic! 

Learn more about the HEAR score for risk stratification of patients presenting with chest pain to the Urgent Care in the most recent Urgent Care RAP episode!

CARE: Chest pain