Approach to chest pain

Question 1

History taking in chest pain

Answer 1

1. Site of chest pain - central, left, right, lower sternal
2. Onset - acute or chronic
3. Character
   - Constricting/compressive/crushing: angina, oesophageal spasm/GERD, anxiety
   - Sharp: pleuritic, pericardium inflammation
4. Radiation
   - Cardiac: shoulder, either/both arms, neck, jaw, epigastric
   - Aortic dissection: tearing, to the back, interscapular, retrosternal
5. Precipitating factors
   - Cardiac: cold, exercise, palpitations, emotions
   - Oesophageal spasm/GERD: food, lying flat, hot drinks, alcohol
   - Inspiration chest pain: pleuritic, musculoskeletal, rib fracture, subdiaphramatic pathology (gallstone, liver capsular stretch)
6. Relieving factors
   - Cardiac: rest, GTN
   - GI: antacids
   - Pleuritic: leaning forward
7. Associated symptoms
   - Dyspnoea: cardiac, PE, pleuritic, anxiety
   - NVD: MI, GI
   - Diaphoresis: MI
   - Giddiness, syncope, headache, lethargy: anaemia, dissection
   - Localised tenderness: musculoskeletal
8. Time and duration
   - Prior exertional chest pain or SOB
   - How frequent, how long ago, duration of each episode

Question 2

Differential diagnoses of chest pain

Answer 2

Emergency
A. Cardiovascular
1. Acute coronary syndromes - USA, NSTEMI, STEMI
2. Aortic dissection -> think of cause
3. Acute pericarditis, myocarditis -> think of cause
4. Pericardial effusion

B. Respiratory
1. Pleural effusion
2. Pneumothorax, haemothorax -> think of cause

C. Gastrointestinal
1. Oesophageal rupture
2. Acute pancreatitis (usually epigastric)

Non-emergency
1. Musculoskeletal pain
2. GERD
3. Gastritis
4. Pleuritic chest pain - pneumonia
5. Mediastinitis