Chest pain

Question 1

List some types of chest pain

Answer 1

Cardiac 
Pericardial 
Oesophageal
Pleural
Vascular
Musculoskeletal
Neurological
Psychological

Question 2

List some acute life threatening causes of chest pain

Answer 2

Myocardial ischaemia/infarction
Massive pulmonary embolus (discussed on Monday)
Ruptured aortic aneurysm
Pericarditis
Acute pneumothorax (discussed on Monday)
Ruptured oesophagus (rare)

Question 3

What causes Angina?

Answer 3

Myocardial ischaemia (ACS)

Question 4

How are angina and MI similar?

Answer 4

Both have similar pain distribution

Question 5

How is MI different to angina?

Answer 5

Severity
Frightening
Lasts hours
Not relieved by nitrates
No precipitating cause
Accompanied by pallor, sweating, vomiting

Question 6

Describe cardiac pain

Answer 6

Front of the chest, mid or upper sternum
Radiating to left arm, both arms, round the chest or into the jaw
Described as tight, heavy, constricting, crushing, numbing or burning
But can be atypical, e.g. in women and diabetics

Question 7

What is included in a chest pain history?

Answer 7

Onset
Site of pain
Quality and intensity
Pattern and duration
Exacerbating factors (eating, exercise, breathing, position or movement)
Associated symptoms (sweating, vomiting, cough, weight loss etc)
Relieving factors (position, medication)

Question 8

What are the typical characteristics of angina?

Answer 8

predictable
related to exercise
worse in cold or windy weather
induced by stress
relieved by nitrates

Question 9

Describe the examination of chest pain

Answer 9

History most important!
Get the basics right:  
Pulse, BP, Resp rate, temp, o2 sats
Document in notes
Thorough examination
Palpate chest
An ECG may be important 
Defensive medicine appropriate with potentially life threatening acute problems

Question 10

What should you give a suspected MI patient?

Answer 10

Aspirin
GTN spray
Diamorphine
O2

Question 11

Describe pericardial pain

Answer 11

Mediastinal pain
May be referred to shoulder & back
Made worse by breathing, coughing & sneezing
Influenced by posture, typically relieved by sitting forward

Question 12

List some causes of pericardial pain

Answer 12

Viral infection

- in context of ‘flu like illness
- Coxsackie virus, mumps, herpes, HIV

Post myocardial infarction

Question 13

Describe pleuritic pain and give some causes

Answer 13

Usually one sided
Worse on inspiration
‘Sharp’, ‘stabbing’ or ‘knife-like’
Severe
Mode of onset & associated symptoms gives clue to aetiology
Dyspnoea/Haemoptysis
Think of pneumonia, pulmonary embolism, pneumothorax and malignancy

Question 14

How is a dissecting aortic aneurysm different from an MI?

Answer 14

More sudden onset
Described as ‘tearing’
Moves from front to back as the dissection extends

Question 15

List some less urgent causes of chest pain

Answer 15

Gastro-oesophageal reflux 
Musculoskeletal pain
Trauma
Malignancy (e.g. lung)
Psychological:  difficult to reassure people with chest pain

Question 16

What are the most common forms of chest pain presented in GP surgeries?

Answer 16

musculoskeletal
angina
oesophageal reflux
anxiety

Question 17

What are the most common forms of chest pain presented in hospitals?

Answer 17

pneumonia
myocardial infarction
pulmonary embolus

Question 18

Describe gastro oesophageal reflux disease

Answer 18

Common
Not dissimilar to cardiac pain
Patients often suffer from both
‘Burning’ discomfort
Induced by bending
Acid, bitter taste in mouth
Relieved by antacid (& sometimes nitrate) 
Improved by raising head of bed & stopping smoking

Question 19

Describe musculoskeletal chest pain

Answer 19

Induced or relieved by postural change
Highly localised
Reproduced by pressure

Question 20

Describe Tietze’s syndrome

Answer 20

M>F, 20-30 years old
Pain localised to costal cartilage
Exacerbated by coughing, sneezing, motion

Question 21

List some dermatological or neurological causes of chest pain

Answer 21

Shingles
Nerve root compression
Collapsed vertebrae
Bone metastasis
Abscess