Chest Pain

Question 1

What are the DDs of chest pain?

Answer 1

CV: 
Angina
MI
Percarditis
Aortic dissection

GI:
Reflux oesophagitis
Peptic ulcer disease
Oesophageal spasm

Pulm:
Pneumonia
Pneumothorax
PE

MSK:
Chest wall injuries
Herpes zoster (shingles)
Costochondritis
Bornholm disease
2* ca of the rib

Emotional:
Depression
Anxiety

Question 2

How can the character of the pain help the diagnosis?

Answer 2

Tight/constricting - angina

Tearing - aortic dissection

Burning - oeso reflux

Sharp - pleura, pericardium, chest wall

Crushing & prolongued - MI

Question 3

How can radiation help the diagnosis?

Answer 3

Shoulder, arms, neck, jaw - MI/cardiac

Interscapular - aortic dissection

Retrosternal - oeso reflux, aortic dissection

Trapezius ridge - pericarditis

Question 4

How do the precipitating factors affect your diagnosis?

Answer 4

Known precipitants of angina are emotion, food and cold weather.

Lying down - decubitus angina or oesophageal reflux

Food/drinks/alc - oeso reflux
At rest for +20 mins = MI unless proven otherwise.

Worse on inspiration: pericarditis, pulmonary infection/inflamm/infarct, MSK

Question 5

How do the relieving factors affect your diagnosis?

Answer 5

Rest/GTN relief: angina or oeso spasm if slower relief
Antacids: oeso reflux
Sitting forwards: pericarditis

Question 6

What would a history of trauma make you think?

Answer 6

Rib fracture

Question 7

Which associated symptoms can help diagnosis?

Answer 7

Dyspnoea: 
Cardiac pain
PE
Pleurisy
Angina

Palpitations:
Thyrotoxicosis
Ectopics
AF, SVT, VT
Phaeochromocytoma

Tenderness: Tietze’s syndrome (costochondritis)

Hx of:
AS
CAD

Odd neuro symptoms:
Aortic dissection

Question 8

What more do you ask about dyspnoea?

Answer 8

Orthopnoea? HF, PO
Paroxysmal nocturnal dyspnoea? HF
On exertion? A
Has tolerance changed?