Chest Pain

Question 1

OSOCRATES

Answer 1

Open question
Site- point to exactly where it is
Onset- when did it start/ what were you doing/ gradual or acute
Character- describe the pain
Radiation- does it go anywhere
Associated features- discussed later
Timing- does it come and go or is it constant/ have you had this before
Exacerbating and relieving factors- related to food/ breathing/ position/ what makes it better etc.
Severity- 1-10

Question 2

Relevant systems review

Answer 2

General- FWARLNJ

Cardiorespiratory- palpitations, breathless when lying flat, wheeze, cough, sputum, heamoptysis, leg swelling, paroxysmal nocturnal dyspnoea (waking up at night)

MSK- pain worse on movement, hurt to press on the area

Question 3

ACS (better to say than MI)

Answer 3

Sudden crushing central chest pain 
Radiated to arm, neck 
Associated nausea, SOB, sweatiness
Cardiovascular risk factors
Pain different to their usual angina

Question 4

Stable angina

Answer 4

Cardiac type chest pain- can radiate to usual places
Associated with exertion and no relation to food
Relieve by rest
Associated with breathlessness, but sweating, nausea and vomiting are not typical
No relief from GTN/ longer than 20 minutes- unlikely to be stable angina

Question 5

Pericarditis

Answer 5

Retrosternal pleuritic chest pain
Relieved by sitting forward
May radiate to trapezius ridge, neck, shoulder
Aggravated by coughing

Question 6

PE

Answer 6

Pleuritic chest pain
SOB
Haemoptysis
Fever
Risk factors- clotting disorder/ cancer/ recent surgery/ long journeys/ pregnancy
Signs of a DVT (swollen hot tender leg unilaterally)

Question 7

Pneumothorax

Answer 7

Sudden onset chest pain
SOB
Risk factors
Background history of lung disease or collagen disease eg. Marfan’s or recent chest trauma (insertion of a central line)

Question 8

GORD

Answer 8

Retrosternal burning chest pain, worse on lying flat and after eating a bit meal
Related to meals, lying and standing
Taste acid in mouth
Relieved by swallowing saliva or water, or taking antacids

Question 9

Anxiety attack

Answer 9

Tight chest pain, SOB, sweating, dizziness, palpitations, anxious personality, recurrent episodes, usually a trigger eg. Crowds

Question 10

MSK

Answer 10

Localised, pleuritic (sharp) chest pain with no other symptoms 
Exacerbated by movement and inspiration 
Can point to where it’s the worse 
Exacerbated by pressure over the area
Perhaps a history of trauma

NB- includes costochondritis

Question 11

Pleuritic pain

Answer 11

More likely to be PE, pericarditis, pneumonia, costochondritis

Question 12

Red flags chest pain

Answer 12

Sudden onset
Duration >10 minutes
Not relived by GTN
Associated dyspnoea
Exertional
Risk factors for PE
Weight loss
New dyspepsia >55 y/o

Question 13

Patients perspective

Answer 13

Feelings
Ideas what may be causing it
Anything particularly concerning you
Expectations

Question 14

PMH

Answer 14

Angina diabetes HTN reflux

PE risk factors eg. Clotting disorders/ cancers/ recent surgery/ long flights recently

Question 15

DH

Answer 15

Regular medications sprays pills allergies OTC

Question 16

FH

Answer 16

Family history of heart disease or anything else?
If heart disease, clarify age of family members (significant in men if below 55, women below 65)
Ask about hypercholesterolaemia and clotting disorders

Question 17

SH

Answer 17

Have you ever smoked
Alcohol recreational drugs
Are you working, has the problem impacted your work?
Home situation (occupants and difficulties)

Question 18

Important points

Answer 18

Clarify whether an acute event- could be more serious
Sharp pain- more likely to be parietal than visceral ie. less likely to be ACS (cardiac pain is dull and often described as a tightness, weight, heavy discomfort)
Pleuritic pain- sharp pain on inspiration (PE, pericarditis, pneumonia, costochondritis)

Question 19

Pneumonia

Answer 19

Hx of cough and purulent sputum with general malaise and fever
Pleuritic pain with haemoptysis, wheezing, and SOB
May be background of respiratory disease eg. COPD

Question 20

Aortic dissection

Answer 20

Sudden onset of severe tearing/ripping pain felt between shoulder blades
May have a recent history of trauma eg. Traffic accident, background of HTN or Ehler danlos/ Marfan’s syndrome
Wide range of Sx inc. ishcameic limbs, stroke, decreased urine output, MI etc.

Question 21

Investigations

Answer 21

Cardiorespiratory examination
12 lead ECG
Bloods- FBC UE CRP troponin (I and T, baseline and 12 hours), caution with D dimer
CXR
CT angio (if suspect aortic dissection)
CTPA if PE suspected
Coronary angiography (if angina or ACS suspected)
Endoscopy (if other GI red flags present)