Approach to chest pain and shortness of breath (incomplete)

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
   - Sharp
4. Radiation
   - Shoulder, either/both arms, neck, jaw, epigastric
   - Tearing, to the back, interscapular, retrosternal
5. Precipitating factors
   - Position - lying flat
   - Food intake
   - Exertion
6. Relieving factors
   - Position - leaning forward
   - Rest
   - Antacid use
7. Associated symptoms
   - Dyspnoea
   - NVD
   - Diaphoresis
   - Giddiness, syncope, headache, lethargy
   - Localised tenderness
8. Time and duration
   - Prior exertional chest pain or SOB
   - How frequent, how long ago, duration of each episode

Character
- Constricting/compressive/crushing: angina, oesophageal spasm/GERD, anxiety
- Sharp: pleuritic, pericardium inflammation

Radiation
- Cardiac: shoulder, either/both arms, neck, jaw, epigastric
- Aortic dissection: tearing, to the back, interscapular, retrosternal

Precipitating factors
- Cardiac: cold, exercise, palpitations, emotions
- Oesophageal spasm/GERD: food, lying flat, hot drinks, alcohol
- Inspiration chest pain: pleuritic, musculoskeletal, rib fracture, subdiaphragmatic pathology (gallstone, liver capsular stretch)

Relieving factors
- Cardiac: rest, GTN
- GI: antacids
- Pleuritic: leaning forward

Associated symptoms
- Dyspnoea: cardiac, PE, pleuritic, anxiety
- NVD: MI, GI
- Diaphoresis: MI
- Giddiness, syncope, headache, lethargy: anaemia, dissection
- Localised tenderness: musculoskeletal

Question 2

Chest pain character
- Constricting/compressive/crushing: angina, oesophageal spasm/GERD, anxiety
- Sharp: pleuritic, pericardium inflammation

Question 3

Chest pain radiation
- Cardiac: shoulder, either/both arms, neck, jaw, epigastric
- Aortic dissection: tearing, to the back, interscapular, retrosternal

Question 4

Precipitating factors for chest pain
- Cardiac: cold, exercise, palpitations, emotions
- Oesophageal spasm/GERD: food, lying flat, hot drinks, alcohol
- Inspiration chest pain: pleuritic, musculoskeletal, rib fracture, subdiaphragmatic pathology (gallstone, liver capsular stretch)

Question 5

Relieving factors for chest pain
- Cardiac: rest, GTN
- GI: antacids
- Pleuritic: leaning forward

Question 6

Associated symptoms of chest pain
- Dyspnoea: cardiac, PE, pleuritic, anxiety
- NVD: MI, GI
- Diaphoresis: MI
- Giddiness, syncope, headache, lethargy: anaemia, dissection
- Localised tenderness: musculoskeletal

Question 7

Differential diagnoses of chest pain

Answer 7

Emergency
A. Cardiovascular
1. Acute coronary syndromes - USA, NSTEMI, STEMI
2. Pericarditis, myocarditis -> autoimmune, infection
3. Pericardial effusion
4. HOCM
5. Valvular disease - Marfan, ADPKD, AnkSpon, autoimmune CTD
6. Infective endocarditis
7. Anaemia related coronary syndrome - Bleeding; Iron/Fol/B12 defs; Haemolysis; bone marrow disorder

B. Vascular
1. Aortic dissection -> think of cause
2. Aortitis, TAA - Takayasu, GCA

C. Respiratory
1. Pleural effusion
2. Pneumothorax, haemothorax -> Marfan’s; TSC; COPD, Bronchiectasis
3. Pulmonary embolism - APS, Nephrotic syndrome, IBD, MPN, Cancers, OCP/HRT; Wells scoring
4. Pneumonia

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