Chest pain presents a diagnostic challenge in outpatient family medicine. Noncardiac causes are common, but it is important not to overlook serious conditions such as an acute coronary syndrome, pulmonary embolism, or pneumonia. In addition to a thorough history and physical examination, most patients should have a chest radiograph and an electrocardiogram. Patients with chest pain that is predictably exertional, with electrocardiogram abnormalities, or with cardiac risk factors should be evaluated further with measurement of troponin levels and cardiac stress testing. Risk of pulmonary embolism can be determined with a simple prediction rule, and a D-dimer assay can help determine whether further evaluation with helical computed tomography or venous ultrasound is needed. Fever, egophony, and dullness to percussion suggest pneumonia, which can be confirmed with chest radiograph. Although some patients with chest pain have heart failure, this is unlikely in the absence of dyspnea; a brain natriuretic peptide level measurement can clarify the diagnosis. Pain reproducible by palpation is more likely to be musculoskeletal than ischemic. Chest pain also may be associated with panic disorder, for which patients can be screened with a two-item questionnaire. Clinical prediction rules can help clarify many of these diagnoses.

Adult↗

PubMed2005

Irritable bowel syndrome.

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Adult↗

PubMed2005

Evidence-based medicine for medical students: introducing EBM in a primary care rotation.

BACKGROUND AND OBJECTIVES: Evidence-based medicine (EBM) seeks to improve patients' lives by applying the best available evidence to decisions affecting health outcomes. Since medical students often do not appreciate the value of an evidence-based approach to medicine when they enter third-year clinical training, a curriculum was developed introducing third-year students to the practice of EBM during a primary care clinical rotation. METHODS: Twenty-seven students over 4 rotations participated in the series of 6 hour-long seminars, and 8 items from a 27-item questionnaire were used to measure the impact on students' self reported understanding and use of EBM. RESULTS: Responses to questionnaires given before and after completion of the curriculum documented improved self-reported understanding of EBM and improved self-reported comfort with critical appraisal. CONCLUSIONS: A seminar series introducing EBM in a primary care rotation improved students' familiarity with and receptivity to use of EBM.

Curriculum↗

PubMed2004