Chest Pain

Question 1

M u s c u l a r s t r a i n s

Answer 1

L o c a l i z e d
s h a r p
p a i n , W o r s e
w i t h
m o v e m e n t
o f
s h o u l d e r s
c h e s t w a l l
t e n d e r , l a s t s
f o r
m i n u t e s
o r prolonged

Question 2

T h o r a c ic
h e r p e s
z o s t e r

Answer 2

S e v e r e , f o l l o w s ..n e r v e ..r o o t

d i s t r i b u t i o n , p r e c e d e s ..v e s i c u l a r ..r a s h .

Question 3

LESS SERIOUS CAUSES

Answer 3

 Costochondral Pain

 Chest Wall Pain

 Esophageal Pain

 Emotional Disorders

Question 4

OTHER CAUSES

Answer 4

(1) Cervical disk disease.
(2) Osteoarthritis of cervical or thoracic
spine
(3) Abdominal disorders: peptic ulcer,
hiatus hernia, pancreatitis, biliary colic
(4) Tracheobronchitis, pneumonia
(5) Diseases of the breast (inflammation,
tumor)
(6) Intercostal neuritis (herpes zoster)

Question 5

Examination findings

Answer 5

 Examination is often normal but may reveal risk factors
such as xanthelasma indicating hyperlipidaemia.
 Signs of anaemia or thyrotoxicosis may be identified, both
of which can exacerbate angina.
 Cardiovascular examination may reveal left ventricular
dysfunction or cardiac murmurs in patients with aortic
valve disease and hypertrophic cardiomyopathy.
 Evidence of arterial disease, such as bruits and loss of
peripheral pulses, may also be observed.
 History and examination may reveal pallor or sweating
caused by accompanying autonomic disturbance,
arrhythmia, hypotension or heart failure.

Question 6

Investigations

Answer 6

 Initial triage is by 12-lead ECG and serum troponin I or
T.
 Acute coronary syndrome is suggested by ST elevation
or depression and elevated troponin I or T, indicating
myocardial damage.
 If the diagnosis remains unclear, repeat ECGs are
useful, particularly if recorded during pain.
 If baseline plasma troponin is normal, repeat
measurements should be made 6 to 12 hours after the
onset of symptoms or after admission.
 New ECG changes or elevated troponin confirm the
diagnosis of an acute coronary syndrome.
 If the pain settles, there are no new ECG changes and
troponin remains normal, the patient can be
discharged, but further investigations may still be
indicated.

Question 7

Further Investigations

Answer 7

 Blood count, fasting glucose, lipids,
thyroid function tests are the basic
investigations.
 An exercise ECG may identify high-risk
patients requiring further investigation, but
false-negative and false-positive results
can occur.
 Patients with chest pain suggestive of
coronary disease but with a normal
exercise ECG should undergo CT
coronary angiography.
 If a murmur is found, echocardiography
should be performed to exclude valve
disease or hypertrophic cardiomyopathy