Cardiac Differential Diagnosis Will/Grundy EMS Continuing Education January 2011 Written by: -Laurie Carroll, RN, Advocate Bolingbrook Hospital -Will/Grundy EMS Staff

Differential Diagnosis of Chest Pain There are literally dozens of illnesses, injuries and conditions that can cause chest pain. Knowing common signs, symptoms and patient presentations can help you differentiate between different kinds of chest pain. Bottom Line: If you are ever not sure what kind of chest pain you are dealing with, treat it as cardiac and call medical control.

Differential Diagnosis of Chest Pain Common Causes of Chest Pain Cardiovascular: ischemia (AMI or angina) pericarditis (irritation of pericardium) thoracic aortic dissection

Differential Diagnosis of Chest Pain Common Causes of Chest Pain Respiratory: PE (pulmonary embolism) pneumothorax pneumonia pleural irritation hyperventilation (anxiety)

Differential Diagnosis of Chest Pain Common Causes of Chest Pain Gastrointestinal: cholecystitis (gall bladder/gallstones) pancreatitis hiatal hernia (part of stomach pushes through diaphragm) esophageal disease/GERD peptic ulcers dyspepsia (indigestion)

Differential Diagnosis of Chest Pain Common Causes of Chest Pain Musculoskeletal: chest wall syndrome (inflamed chest wall) costochondritis (inflamed rib cartilage) herpes zoster (shingles) chest wall trauma chest wall tumors

QUESTIONS TO HELP DIFFERENTIATE CHEST PAIN CAUSE ONSET OF PAIN CHARACTERISTIC OF PAIN LOCATION OF PAIN HISTORY ASSOCIATED SX/SX AGGRAVATING FACTORS RELIEVING FACTORS

DETERMINE ONSET/DURATION OF PAIN Was it… Sudden? Gradual? Lasts Minutes? Lasts Hours? Varies?

“QUALITY” OF PAIN PLEURITIC (sharp pain with inhalation) SPASMODIC (like a spasm) TIGHTNESS OR HEAVINESS PRESSURE- OPPRESSIVE SHARP/LOCALIZED (easy to pinpoint) VISCERAL (hard to pinpoint)/BURNING TEARING / EXCRUCIATING

LOCATION SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE

HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HTN, CAD, ANGINA PHLEBITIS

Associated Signs/Symptoms? DYSPNEA DIAPHORESIS NAUSEA / VOMITING AMS /WEAKNESS /LIGHTHEADEDNESS / SYNCOPE NEURO CHANGES HYPO OR HYPERTENSION OR UNEQUAL BP DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS HEMOPTYSIS (coughing up blood) PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS

AGGRAVATING FACTORS? BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY

RELIEVING FACTORS – What makes it feel better? REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS

Now lets match the chest pain diagnosis with the symptoms…. The list items in red italics are the ones that go with the diagnosis….

ANGINA ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies

ANGINA QUALITY PLEURITIC SPASMODIC TIGHTNESS OR HEAVINESS PRESSURE- OPPRESSIVE SHARP/LOCALIZED VISCERAL/BURNING TEARING / EXCRUCIATING

ANGINA LOCATION SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE

ANGINA HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HTN, CAD, ANGINA PHLEBITIS

ANGINA ASSOCIATED SX / SX DYSPNEA DIAPHORESIS NAUSEA / VOMITING AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE NEURO CHANGES HYPO OR HYPERTENSION OR UNEQUAL BP DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS HEMOPTYSIS PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS

ANGINA AGGRAVATING FACTORS BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY

ANGINA RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS

Acute Myocardial Infarction ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies

Acute Myocardial Infarction QUALITY PLEURITIC SPASMODIC TIGHTNESS OR HEAVINESS PRESSURE- OPPRESSIVE SHARP/LOCALIZED VISCERAL/BURNING TEARING / EXCRUCIATING

Acute Myocardial Infarction LOCATION SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE

Acute Myocardial Infarction HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HTN, CAD, ANGINA PHLEBITIS

Acute Myocardial Infarction ASSOCIATED SX / SX DYSPNEA DIAPHORESIS NAUSEA / VOMITING AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE NEURO CHANGES HYPO OR HYPERTENSION OR UNEQUAL BP DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS HEMOPTYSIS PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS

Acute Myocardial Infarction AGGRAVATING FACTORS BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY

Acute Myocardial Infarction RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS

Dissecting Aneurysm ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies

Dissecting Aneurysm QUALITY PLEURITIC SPASMODIC TIGHTNESS OR HEAVINESS PRESSURE- OPPRESSIVE SHARP/LOCALIZED VISCERAL/BURNING TEARING / EXCRUCIATING

Dissecting Aneurysm LOCATION SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE ABDOMEN

Dissecting Aneurysm HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HTN, CAD, ANGINA PHLEBITIS

Dissecting Aneurysm ASSOCIATED SX / SX DYSPNEA DIAPHORESIS NAUSEA / VOMITING AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE NEURO CHANGES HYPO OR HYPERTENSION OR UNEQUAL BP DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS HEMOPTYSIS PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS

Dissecting Aneurysm AGGRAVATING FACTORS BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY In other words, it hurts badly no matter what.

Dissecting Aneurysm RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS In other words, nothing helps it feel better.

PERICARDITIS ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies

PERICARDITIS QUALITY PLEURITIC SPASMODIC TIGHTNESS OR HEAVINESS PRESSURE- OPPRESSIVE SHARP/LOCALIZED VISCERAL/BURNING TEARING / EXCRUCIATING

PERICARDITIS LOCATION SUBSTERNAL CENTER OR ACROSS CHEST/RETROSTERNAL LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE

PERICARDITIS HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HTN, CAD, ANGINA PHLEBITIS

PERICARDITIS ASSOCIATED SX / SX DYSPNEA DIAPHORESIS NAUSEA / VOMITING AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE NEURO CHANGES HYPO OR HYPERTENSION OR UNEQUAL BP DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS HEMOPTYSIS PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS PARADOXICAL PULSE

PERICARDITIS AGGRAVATING FACTORS BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY

PERICARDITIS RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS

PNEUMOTHORAX ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies

PNEUMOTHORAX QUALITY PLEURITIC SPASMODIC TIGHTNESS OR HEAVINESS PRESSURE- OPPRESSIVE SHARP/LOCALIZED VISCERAL/BURNING TEARING / EXCRUCIATING

PNEUMOTHORAX LOCATION SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE

PNEUMOTHORAX HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HTN, CAD, ANGINA PHLEBITIS

PNEUMOTHORAX ASSOCIATED SX / SX DYSPNEA DIAPHORESIS NAUSEA / VOMITING AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE NEURO CHANGES HYPO OR HYPERTENSION OR UNEQUAL BP DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS HEMOPTYSIS PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS

PNEUMOTHORAX AGGRAVATING FACTORS BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY

PNEUMOTHORAX RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS

PULMONARY EMBOLISM ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies

PULMONARY EMBOLISM QUALITY PLEURITIC SPASMODIC TIGHTNESS OR HEAVINESS PRESSURE- OPPRESSIVE SHARP/LOCALIZED VISCERAL/BURNING TEARING / EXCRUCIATING

PULMONARY EMBOLISM LOCATION SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE

PULMONARY EMBOLISM HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HTN, CAD, ANGINA PHLEBITIS SMOKING/RECENT SURGERY/BCP (birth control pill)

PULMONARY EMBOLISM ASSOCIATED SX / SX DYSPNEA DIAPHORESIS NAUSEA / VOMITING AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE NEURO CHANGES HYPO OR HYPERTENSION OR UNEQUAL BP DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS HEMOPTYSIS PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS

PULMONARY EMBOLISM AGGRAVATING FACTORS BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY

PULMONARY EMBOLISM RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS

HIATAL HERNIA ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies

HIATAL HERNIA QUALITY PLEURITIC SPASMODIC TIGHTNESS OR HEAVINESS PRESSURE- OPPRESSIVE SHARP/LOCALIZED VISCERAL/BURNING TEARING / EXCRUCIATING

HIATAL HERNIA LOCATION SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE

HIATAL HERNIA HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HTN, CAD, ANGINA PHLEBITIS

HIATAL HERNIA ASSOCIATED SX / SX DYSPNEA DIAPHORESIS NAUSEA / VOMITING AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE NEURO CHANGES HYPO OR HYPERTENSION OR UNEQUAL BP DECREASED OR ABNORMAL BREATH SOUNDS CYANOSIS HEMOPTYSIS PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS

HIATAL HERNIA AGGRAVATING FACTORS BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY

HIATAL HERNIA RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS

GASTROINTESTINAL ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies

GASTROINTESTINAL QUALITY PLEURITIC SPASMODIC TIGHTNESS OR HEAVINESS PRESSURE- OPPRESSIVE SHARP/LOCALIZED VISCERAL/BURNING TEARING / EXCRUCIATING

GASTROINTESTINAL LOCATION SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE

GASTROINTESTINAL HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HTN, CAD, ANGINA PHLEBITIS Maybe none…. For example, food poisoning doesn’t require a history other than recent eating.

GASTROINTESTINAL ASSOCIATED SX / SX DYSPNEA DIAPHORESIS NAUSEA / VOMITING AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE NEURO CHANGES HYPO OR HYPERTENSION OR UNEQUAL BP DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS HEMOPTYSIS PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS

GASTROINTESTINAL AGGRAVATING FACTORS BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY

GASTROINTESTINAL RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS

PNEUMONIA/PLEURISY ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies

PNEUMONIA/PLEURISY QUALITY PLEURITIC SPASMODIC TIGHTNESS OR HEAVINESS PRESSURE- OPPRESSIVE SHARP/LOCALIZED VISCERAL/BURNING TEARING / EXCRUCIATING

PNEUMONIA/PLEURISY LOCATION SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE

PNEUMONIA/PLEURISY HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HTN, CAD, ANGINA PHLEBITIS

PNEUMONIA/PLEURISY ASSOCIATED SX / SX DYSPNEA DIAPHORESIS NAUSEA / VOMITING AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE NEURO CHANGES HYPO OR HYPERTENSION OR UNEQUAL BP DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS HEMOPTYSIS PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS

PNEUMONIA/PLEURISY AGGRAVATING FACTORS BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY

PNEUMONIA/PLEURISY RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS

HYPERVENTILATION/ANXIETY ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies

HYPERVENTILATION/ANXIETY QUALITY PLEURITIC SPASMODIC TIGHTNESS OR HEAVINESS PRESSURE- OPPRESSIVE SHARP/LOCALIZED VISCERAL/BURNING TEARING / EXCRUCIATING VAGUE/DIFFUSE

HYPERVENTILATION/ANXIETY LOCATION SUBSTERNAL CENTER OR ACROSS CHEST LATERAL CHEST LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK OR ARM VAGUE

HYPERVENTILATION/ANXIETY HISTORY AGE PREVIOUS EPISODES UPPER RESPIRATORY INFECTION/FEVER TRAUMA STRESS EMOTIONAL UPSET CARDIAC DISEASE – HTN, CAD, ANGINA PHLEBITIS

HYPERVENTILATION/ANXIETY ASSOCIATED SX / SX DYSPNEA DIAPHORESIS NAUSEA / VOMITING AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE NEURO CHANGES HYPO OR HYPERTENSION OR UNEQUAL BP DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS HEMOPTYSIS PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS INCREASED RESP RATE NUMBNESS –EXTREMITIES/FACE

HYPERVENTILATION/ANXIETY AGGRAVATING FACTORS BREATHING MOVEMENT STRESS EXERTION AFTER EATING OR ETOH LAYING DOWN SITUATIONAL / ANXIETY

HYPERVENTILATION/ANXIETY RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION SITTING UP OR LEANING FORWARD DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS DECREASED ANXIETY

And now…. It’s time for Call Type of the Month!

Will/Grundy Call Type of the Month Fall call! Not this kind…. This kind!

Will/Grundy Call Type of the Month Most important thing to remember: Falling is a symptom, not a complaint. There is always a reason why they fell. Tripped Dexi Dizzy Dead Etc.

Will/Grundy Call Type of the Month Fall assessment is targeted toward determining and treating associated injuries and possible causes – as well as ruling out pertinent negatives. Narratives/PCR’s need to reflect this process. This is not enough: “Called to 62yo female a&ox3 but lethargic, laying in bathroom, 1 in. lac r temple. Bleeding ctx w/4x4. Pt c/o upper back pain. Family sez they fall a lot. Pt board/collar, vitals as per below, head-to-toe, etc, etc, etc….”

Will/Grundy Call Type of the Month EMS crews need to provide clues from the scene to help ER staff answer the question: Why did this patient fall? Was it sugar? Cardiac? Blood pressure? Heat? Rug needs to be taped down? Better: “Called to 62yo female a&ox3 but lethargic, laying in bathroom, 1 in. lac r temple. Bleeding ctx w/4x4. Pt c/o upper back pain. Family sez they fall a lot. Pt stated she felt dizzy as she got up from commode. Pt states she often feels dizzy in the mid-morning. Crew notes pt BP is lower than BP recorded by home CNA in am. Pt board/collar, head-to-toe, etc, etc, etc…”

Will/Grundy Call Type of the Month Absolutely no idea why they fell? Well, if after a thorough assessment and treatment you have no clues to report, then stick to the pertinent negatives: Example: “Called to 62yo female a&ox3 but lethargic, laying in bathroom, 1 in. lac r temple. Bleeding ctx w/4x4. Pt c/o upper back pain. Pt states does not remember falling. Family unable to offer hx due to lang. barrier. Crew notes no obvious slip/fall hazards in bathroom. Etc, etc, etc…...”

Will Grundy Call Type of the Month Summary: Many fall calls need ALS care. It’s tempting at 2am to just board, collar and transport. But there is always a reason why they fell. We are the eyes and ears of the doctor on the scene. So we need to gather clues during the assessment process.

Thank you!