Chest pain

Question 1

What should you be warry of when a pt complains of chest pain?

Answer 1

• MI
• PE
• Dissecting aneurysm
• Pericarditis

Question 2

What should you do when a pt rings in for a chest pain and is acutely unwell?

Answer 2

• arrange a 999 ambulance in advance

Question 3

What are the differentials for chest pain

Answer 3

• Cardiac related
  
  • stable angina
  • ACS
  • Prinzmetal’s angina (coronary vasospasm)
  • Aortic stenosis
  • hypertrophic cardiomyopathy
• Respiratory
  
  • Pneumothorax
  • PE
  • Pneumonia
  • Pleurisy
  • Lung cancer
• MSK
  
  • ​Tietze’s syndrome
• GI
  
  • oesophageal rupture
  • PUD
  • GORD
  • cholecystisis
  • pancreatitis
  • gastritis

Question 4

Describe the Hx taking for chest pain in primary care

Answer 4

• Pain: site, radiation, nature (type, frequency, severity), onset, duration, variation with time, modifying factors (eg, exercise, rest, eating, breathing or medication) and any previous episodes.
• Visceral or somatic chest pain
• Associated sx
• Consider RF for Coronary Heart Disease
• Refer to previous ECGs and any previous cardiac ix
• Exclude thrombolysis contraindications if ACS suspected
• PMH
• FH

Question 5

How do you get pain felt in jaw and left arm in viscersal pain?

Answer 5

• Pain transmitted via the autonomic system but may be referred via an adjacent somatic nerve

Question 6

What are the types of associated sx in chest pain?

Answer 6

• GI/cardiac cause: Anorexia, nausea, vomiting
• Resp/cardiac cause: Breathlessness, cough, haemoptysis
• Shock: Excessive sweating
• Cardiac cause: Palpitations, dizziness, syncope

Question 7

What examination would you perform for chest pain?

Answer 7

• BP in both arms
• CVS and resp ex
• Look for signs of chest trauma
• Abdo exam, legs and skin

Question 8

What Ix would you perform?

Answer 8

• FBC (to exclude anaemia).
• Renal function tests and electrolytes.
• TFTs.
• CRP.
• Fasting lipids and glucose.
• Resting ECG
• Additional tests if a non-cardiac cause is suspected
  
  • CXR
  • LFT
  • amylase
  • abdo US

Question 9

How would you mx MI and unstabkle angina?

Answer 9

• Arrange immediate transfer to hospital

Whilst waiting for the ambulance

• Aspirin 300mg PO
• IV cannula
• IV Morphine 2.5-5mg. Repeat 15mins if needed
• IV Metoclopramide 10mg
• Sublingual GTN
• Give O2
• IV atropine 300mcgm if bradycardia
• Consider thrombolysis of hospital transfer >30mins

Question 10

What are the typical clinical features of MI?

Answer 10

• Collapse +/- cardiac arrest
• Breathlessness
• N&V
• Fear of dying
• Pain radiating to arm, jaw

Question 12

How would you mx Ventricular Tachycardia?

Answer 12

• Admit as blue light emergency
• Give O2
• 100mg IV lidocaine
• If no pulse > treat as VF

Question 13

How would you mx paroxysmal supraventricular tachycardia?

Answer 13

• ECG
• Carotid sinus massage or vasalva manoeuvre
• Admit as emergency
• If attack stops > refer cardiology

Question 14

How would you mx HB?

Answer 14

• BP <90, LVF, HR<40 —> admit as emergency
• Give IV atropine and O2 while awaiting admission