46. Chest pain (resp)

Question 1

Differentials.

a) Cardiac
b) Non-cardiac - most common, and others (resp, GI, MSK, etc.)
c) Most dangerous - need to exclude

Answer 1

a) Cardiac.
- Ischaemic heart disease (angina, unstable angina, NSTEMI, STEMI)
- Inflammatory: pericarditis, endocarditis, myocarditis
- Structural: valvular (AS), cardiomyopathy (HCM)
- Aortic dissection

b) Non-cardiac.
- Most common - GORD
- Resp - pleurisy (e.g. pneumonias, PE), pneumothorax
- MSK - rib #, costochondritis
- GI - oesophageal spasm, malignancy, rupture, pancreatitis
- Neuromuscular (e.g. nerve root pain - shingles)
- Non-organic - fibromyalgia, psychiatric (panic attack)

c) Dangerous.
- CV - ACS, aortic dissection
- Resp - PE, pneumothorax

Question 2

History.

a) SOCRATES
b) Associated cardiac symptoms
c) Associated resp symptoms
d) Associated GI symptoms
e) Associated MSK symptoms
f) Other considerations

Answer 2

a) SOCRATES.
- Site: central (ACS), sternocostal (costochondritis), unilateral (pleurisy, shingles)
- Onset: sudden (vascular, trauma), gradual (infection, inflammation)
- Character: dull ache/heavy (ACS), burning (GORD), sharp (pleurisy, trauma, dissection)
- Radiation: jaw, arm (ACS), back (GI, dissection, pericarditis)
- Ass Sx
- Timing: constant > 15 mins (ACS), intermittent (vasospasm, oesophageal spasm)
- Exacerbating/relieving factors: GTN/exercise (ischaemia/ cardiac), food (GI), tender to touch (MSK, shingles), leaning forward (pericarditis), deep inspiration (pleurisy)
- Severity

b) - ACS: sweaty, nausea/vomiting
- Other: SOB, syncope, palpitations

c) SOB, cough, sputum, wheeze, fever, haemoptysis
d) Acid reflux, related to food, vomiting
e) Tenderness, related to position

f) Psych - panic attack symptoms
Malignancy - weight loss, anorexia, TATT, anaemia, etc.

Question 3

History.

a) PMHx
b) DHx
c) FHx
d) SHx

Answer 3

a) - Cardiac - angina/previous MI, valve disease, AF, etc.
- Resp - previous PE, pneumothorax, other resp disease
- GI - known reflux, etc.

b) - Relievers - GTN (?angina/ACS), NSAIDs (?MSK), etc.
- Risks - COCP (?PE), NSAIDs (?PUD)

c) - MI before age 65
- Sudden cardiac death

d) - Smoking
- Alcohol, drugs (eg. cocaine)
- Occupation
- Social support, carers, independence (how far can you walk on the flat?), etc.

Question 4

Examination.

a) Vital signs (abnormalities in each may indicate…?)
b) A-E assessment
c) Other

Answer 4

a) - Hypoxia - ACS, pneumonia, PE, pneumothorax
- Tachypnoea - pneumonia, PE, ACS, pneumothorax
- Hypotension - ACS, PE, sepsis
- Tachycardia - ACS, PE, panic attack, sepsis
- Pyrexia - pneumonia, endocarditis, PE, other

b) Airway -
Breathing - wheeze, crackles, chest expansion, etc.
Circulation - HS (murmurs - AS), instability
Disability - GCS, glucose, pupils, ?neurology
Exposure - temp, abdomen, calves (PE)

Question 5

Investigations.

a) Bedside
b) Bloods
c) Imaging
d) Special tests

Answer 5

a) - ECG (serial ECGs may be needed)

b) - FBC, CRP, U+Es, clotting, glucose, lipids, TFTs, LFTs
- Troponins 3h intervals
- ?D-dimer (?PE)
- ?amylase (pancreatitis)

c) - CXR
- ?CTPA

d) - ?Angiography/ PCI
- ?UGI endoscopy