Chest Pain

Question 1

What are the systems that can cause chest pain?

Answer 1

Cardiac
Respiratory
GI
Musculoskeletal
Psych

Question 2

What are some differentials for chest pain?

Answer 2

Cardiac
> IHD (MI/ Angina)
> Pericarditis
> Aortic dissection

Respiratory
> Pneumothorax
> Pneumonia
> PE

GI
> Oesophagitis
> Oesophageal spasms
> Heartburn

Musculoskeletal
> Costochondritis

Psych
> Anxiety

Question 3

How might you investigate chest pain?

Answer 3

Bedside
ECG
Echo
BP/ Temp/ Pulse (plus full history and exam)

Biochemical
Bloods- FBC, Troponin, U/E, CRP
Sputum- Culture

Imaging
CXR

Other
(neg trop) Exercise tolerance test
(Pos trop) Coronary angiography

Question 4

How would cardiac causes present?

Answer 4

Radiation to jaw, left arm, pressure- like pain, associated symptoms: sweating, nausea

Dissection= tearing pain and different BP in both arms

Question 5

What might suggest a cardiac cause?

Answer 5

> Previous diagnosis
Age
PMHx (e.g. diabetes, HTN)
Smoking, alcohol

Question 6

What background might suggest an acute respiratory cause?

Answer 6

> Age 
> DVT risk factors (travel, immobility, contraceptive pill)
> Height
> Marfans
> Gender

Question 7

What might suggest GI?

Answer 7

History of GI problems
GI symptoms
Burning pain

Question 8

What might suggest costochondritis?

Answer 8

Insidious onset
Blunt force trauma
Arthritis

Question 9

You are handed an ECG showing ST elevation in leads V1-V4, where is the infarct?

Answer 9

Left anterior descending artery

ANTERIOR MI

Question 10

You are handed an ECG showing ST elevation in leads V5, V6, LI and aVL, where is the infarct?

Answer 10

Circumflex artery

LATERAL MI

Question 11

Which leads will show ST elevation in an inferior MI?

Answer 11

II, III, aVF

Question 12

What do you expect to see on an ECG if there is an anterior MI?

Answer 12

ST elevation in leads V1-4

Question 13

When is CK and troponin highest after an MI?

Answer 13

• CK = within 24 hours

- Troponin = peaks at 2 days

Question 14

What is pleuritic chest pain?

Answer 14

Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling.

Question 15

What ECG findings might you see in a PE?

Answer 15

Sinus tachycardia – the most common abnormality

Complete or incomplete RBBB – associated with increased mortality

Right ventricular strain pattern – T wave inversions in the right precordial leads (V1-4) ± the inferior leads (II, III, aVF)

Question 16

How do you treat:

1. Pneumonia
2. Pneumothorax
3. PE

Answer 16

1. Fluids, antibiotics (augmentin/ tazocin/ co-trimoxazole)
2. (<2cm) needle aspiration or home if young and idiopathic, (>2cm) chest drain
3. Oxygen, fluids, heparin and warfarin, embolectomy/ venous filter

Question 17

How do you treat an MI?

Answer 17

oxygen
morphine
PCI (coronary angiography)
heparin + aspirin
GTN

Question 18

How do you treat pericarditis?

Answer 18

Pericardiocentesis

Question 19

What would you prescribe in an aortic dissection?

Answer 19

Beta blockade
Analgesia
Vasodilators

Question 20

How might you deal with GORD?

Answer 20

PPI

H2 antagonist

Question 21

What would you prescribe for costochondritis?

Answer 21

NSAIDs
PPI
Intra-articular corticosteroid