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OSCE Acute > Approach to Acute Chest Pain > Flashcards

Approach to Acute Chest Pain Flashcards

1
Q

Life-threatening differentials

A
  1. ACS
  2. PE
  3. Aortic dissection
  4. Pneumothorax
  5. Pneumonia
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2
Q

Focussed hx

A

SOCRATES
General SE - malaise, fever, clammy
Chest SE - SOB, wheeze, cough, sputum, leg swelling

PMH - happened before, CVD RF
DH - CVD meds
FH - CV events in close family
SH - smoking, alcohol, long-haul travel

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3
Q

Focussed exam

A 
Tracheal deviation and JVP 
Inspect chest
Expansion, apex, heaves 
Percuss
Auscultate heart and lungs 
Legs - swelling, tenderness, oedema
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4
Q

Investigations

A

Bloods - FBC, CRP, U&E, troponin

X-ray / Imaging - CXR, CTPA (PE), CT angio

ECG

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5
Q

ACS

  • hx
  • exam
  • ix
  • mx
A

Hx

  • crushing central chest pain radiating to neck/ left arm
  • nausea/SOB/sweatiness
  • CVD RF

Exam

  • may be normal
  • general: sweaty, SOB, in pain
  • CV - signs of heart failure, Brady/tachy

Ix

  • ECG - ST elevation, new LBBB, T wave inversion, Q waves
  • Troponin increased
  • CXR normal / signs of heart failure
  • Coronary angiography

MX

  • MONA
  • PCI
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6
Q

Aortic Dissection

  • hx
  • exam
  • ix
  • mx
A

Hx

  • tearing chest pain of very sudden onset radiating to back
  • pain in other sites - i.e. arms, legs, neck, head

Exam

  • unequal arm pulses or BPs
  • may develop acute aortic regurgitation
  • may be new neuro sx due to involvement of carotids/vertebral arteries

Ix

  • CXR - widened mediastinum
  • CT angio
  • ECG - inferior MI

Mx

  • Type A - surgical repair
  • Type B - BP control
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7
Q

Pericarditis

  • hx
  • exam
  • ix
  • mx
A

Hx

  • retrosternal / precordial pleuritic chest pain
  • relieved by sitting forward
  • may radiate to trapezius ridge/neck/shoulder
  • viral prodrome common

Exam

  • pericardial rub (stepping in snow)
  • tachycardia
  • JVP distension and pulses paradoxes may indicate tamponade

Ix - clinical dx

  • ECG - PR depression, saddle ST elevation
  • CXR - may show globular heart if pericardial effusion
  • ECHO - if pericardial effusion suspected

Mx

  • NSAIDs
  • Treat cause if known
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8
Q

Myocarditis

  • hx
  • exam
  • ix
  • mx
A

Hx

  • chest pain
  • palpitations
  • fever
  • fatigue
  • SOB

Exam

  • Signs of heart failure
  • S3 gallop
  • Fever
  • Tachypnoea / tachycardia

Ix

  • ECG - diffuse T wave inversions, ST elevation or depression
  • CRP raised
  • Troponin raised
  • Serology - identify cause
  • Myocardial biopsy (diagnostic) - if required

Mx

  • treat cause
  • treat complications i.e. heart failure
  • bed rest
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9
Q

Other cardiac differentials

A 
Stable angina
Tamponade 
Mitral valve prolapse 
Pulmonary hypertension 
Aortic stenosis
Arrhythmias
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10
Q

Pleurisy

  • hx
  • exam
  • ix
  • mx
A

Hx
- pleuritic chest pain, may have dry cough, fever, SOB

Exam
- pleural rub

Ix - clinical diagnosis
- CXR - exclude pneumothorax, effusion and pneumonia

Mx

  • NSAIDS
  • Treat cause if known
  • Treat complications - effusion, pneumothorax
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11
Q

MSK Chest pain

  • hx
  • exam
  • ix
  • mx
A

Hx

  • sharp chest pain exacerbated by movement and inspiration
  • clearly localised
  • exacerbated by palpation

Exam

  • tenderness over area of pain
  • exam otherwise normal

Ix - diagnosis of exclusion

  • ECG and troponin
  • D-dimer - exclude PE
  • CXR - exclude pneumothorax and infection
  • Normal inflammatory markers

Mx

  • Analgesia
  • Deep breathing exercises to prevent infection
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12
Q

Costochondritis

  • hx
  • exam
  • ix
  • mx
A

Hx

  • costosternal joint pain
  • worse with coughing, twisting and physical activity

Exam

  • Tenderness at sternal edges
  • normal exam otherwise

Ix - diagnosis of exclusion

  • ECG and troponin - exclude MI
  • CXR - normal

Mx

  • NSAIDs
  • Physio
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13
Q

GORD

  • hx
  • exam
  • ix
  • mx
A

Hx

  • retrosternal burning chest pain
  • related to meals, lying, straining
  • water brash

Exam

  • usually normal
  • may be epigastric tenderness if associated gastritis

Ix - clinical diagnosis

  • ECG - exclude MI
  • OGD - if red flags
  • Oesophageal pH monitoring if diagnostic uncertainty

Mx

  • Lifestyle advice
  • PPI
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14
Q

Anxiety / panic attack

A

Hx

  • tight chest pain, SOB, sweaty, dizzy, palpitations, feeling of impending doom
  • anxious personality
  • recurrent episodes triggered by stimulus

Exam - normal, hyperventilation

Ix - exclude

  • MI - ECG and trop
  • Infection - CXR

Mx

  • Reassurance
  • CBT
  • SSRI
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15
Q

Oesophageal spasm

A

Hx

  • intermittent crushing sub-sternal pain
  • relieved by GTN
  • associated dysphagia

Exam - normal

Ix

  • barium swallow - corkscrew oeseophagus
  • oesophageal manometry (diagnostic)

Mx

  • avoid precipitating foods
  • Try - PPI, nitrates, CCB, phosphodiesterase inhibitors, anti-depressants
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16
Q

Other differentials

A 
Gastritis
PUD
Acute cholecystitis 
Pancreatitis 
Tietze syndrome

OSCE Acute (21 decks)

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