Chest pain

Question 1

List differentials for chest pain

Answer 1

CVS: ACS, Angina, Acute pericarditis

RS: PE, Pneumothorax, pneumonia,

GI: GORD, oesophageal spasm, Peptic ulcer, Gallstones, pancreatitis

MSK: Rib fracture, Costochondritis, Muscular pain

Neuro: Anxiety

Other: Aortic Dissection

Question 2

Describe ACS/Angina chest pain (SOCRATES)

Answer 2

S= centralised chest pain
O = sudden onset/exertional/emotional/cold
C = Prolongs dull, central crushing pain or pressure
R = Radiates to shoulder, left arm (can be right), and jaw 
A = Sweating, Nausea, Vomiting, Dyspnoea
T = Prolongeed pain. MI = Not relieved by GTN. Angina is relieved by GTN
E = Angina is relieved by GTN. 
S = Severe chest pain

Question 3

Describe Pneumonia chest pain (SOCRATES)

Answer 3

S =
O = Usually after coughing for long periods
C = Pleuritic chest pain
R = -
A = Cough, dyspnoea, fever, sputum production
T = Progressive
E = Pleuritic pain is exacerbated on inspiration
S = -

Question 4

Describe Pneumothorax chest pain (SOCRATES)

Answer 4

S = Unilateral pain
O = Sudden onset
C = Pleuritic chest pain/ sharp pain 
R =  -
A = Breathlessness, 
T =  - 
E = Pleuritic pain is exacerbated on inspiration
S = -

Question 5

Describe GORD chest pain (SOCRATES)

Answer 5

S = Retrosternal discomfort
O = Usually after food, lying flat, hot drinks or alcohol
C = Heartburn/ Acid pain / indigestion / belching
R = Radiates upwards (GORD)
= Right shoulder (Gallstones)
= Epigastrium (Pancreatitis, Ucer, Gallstone)
A = Nausea, vomiting
T =
E = Exacerbated by food, relieved by anti-acids
S = -

Question 6

Describe acute pericarditis chest pain (SOCRATES)

Answer 6

S = constant retrosternal pain
O = Sudden onset
C = Sharp, stabbing character
R =  To the shoulder, arm or trapezius 
A = Dyspnoea
T = - 
E = Pericarditic pain is relieved on leaning forward
S = -

Question 7

Describe Pulmonary embolism chest pain (SOCRATES)

Answer 7

S = Central chest pain (mimics MI if severe)
O = Usually occurs after DVT 
C = Pleuritic chest pain (if small), crushing pain (if large)
R = - 
A = Dyspnoea, Haemoptysis, (Massive PE can cause Syncope, Shock), 
T = Usually occurs after DVT
E = - 
S = Severe pain

Question 8

Describe musculoskeletal chest pain (SOCRATES)

Answer 8

S = Specific region of pain
O = Gradual onset
C = Severe pain (rib fracture), or 
R =  -
A = 
T = 
E = Varies with posture or movement, Pain on respiration, or gentle pressure to the affected area
S = -

Question 9

Describe Aortic dissection chest pain (SOCRATES)

Answer 9

S =
O = Sudden onset, unrelenting intense chest pain
C = Ripping, sharp, tearing pain
R = Radiates to the back (between shoulder blades)
A = Autonomic upset, syncope or focal neurological deficit
T =
E =
S = Severe

Question 10

Management of suspected cardiac chest pain

Answer 10

1. History
2. examination
3. ECG
   
   • STEMI = ST elevation, Loss of R wave, T wave inversion, new LBBB (anterolateral MI)
     - Anterior MI = V2-V5
     - Lateral MI = V5, V6, I and aVL
     - Posterior MI = II, III, aVF
   • NSTEMI = no ST elevation
4. Pain relief (Morphine)
5. GTN
6. Aspirin (300mg), Fondaparinux, Ticagrelor
7. Troponin (repeated)
   
   • Elevation in STEMI/ NSTEMI