Chest pain Flashcards
What structures in the chest can cause chest pain?
- list the 7 modes of chest pain and their potential cause
Most all structures
- Cardiac (e.g. muscle death / infarction, ischaemia, infection)
- Pericardial (e.g. inflammation, infection)
- Oesophageal (e.g. spasm, inflammation, rupture, varices)
- Pleural (e.g. infection, infarction, embolism, rupture / collapse)
- Vascular (e.g. rupture, inflammation [vasculitis], infection)
- Musculoskeletal (e.g. strain, spasm, tear, rupture, fracture) •
- Neural (e.g. ‘precordial catch, referred pain, neuropathy)
What causes of chest pain are life-threatening?
- Myocardial infarction
- Massive Pulmonary embolus & infarction
- Ruptured aortic aneurysm
- Ruptured oesophagus
What generally indicates that chest pain is cardiac in nature?
- when wouldn’t these general symptoms be present?
- front of the chest, mid or upper sternum
- radiating to the left arm, both arms around the chest or into the jaw
- described as tight, heavy, crushing, numbing or burning
- autonomic neuropathy (e.g diabetes) can reduce cardiac sensation
- women do not often experience these symptoms leading to often silent MIs: some symptoms, nausea, abdominal pain, tachycardia may allude to an underlying serious condition but doesn’t conform to the stereotypical pattern as described above
What is the presenting pain and cause of Pericarditis?
- Mediastinal (central) pain, referred to shoulder & back
- Often sharp in nature, but can be dull
- Made worse by breathing, coughing, sneezing
- Influenced by posture, typically relieved by sitting forward
Cause:
- can happen after an MI - Dressler’s syndrome ( also related to surgery and other traumatic injuries)
- Viral infection:- Coxsackie virus, mumps, herpes, HIV
What is the presenting pain and cause of pain relating to the oesophagus?
common causes are reflux disease: GORD, oesophagitis, oesophageal spasms
- Pain can be burning, crushing, sharp, continuous, wave-like, or acute, can mimic cardiac pain.
- Relieved by more alkaline substances (e.g. milk) and antacids (alginates, H2 antagonists and PPIs being available OTC now).
- Worse after eating, on bending forward / lying flat. Raising the head of bed and smoking cessation
- Chronic, often not sinister, but some features that would make you consider cancer risk (e.g. sudden onset / worsening in older age
- Oesophageal rupture: rare, can be spontaneous following violent vomiting
What is the presenting pain and cause of pain relating to the lungs
- most of the lower respiratory tract is insensitive to pay apart from the pleura
Pain can be related to
- Infection: pneumonia, LRTI
- effusion, empyema, pleurisy (non-specific pleuritic pain)
- Carcinoma, pneumothorax, trauma, a thrombus (PE) and other immunological causes
Describe how pleuritic chest pain presents itself
- Severe ‘sharp’, ‘stabbing’ or ‘knife-like’
- Usually, one-sided
- Worse on inspiration
What is the Wells DVT and PE scoring tool and the PE rule-out criteria PERCs
What are potential vascular causes of chest pain, and how do they present?
Cause: Aortic dissection ( very rare)
- has a more sudden onset that an MI, described as tearing
- moves from front to back as the dissection extends
- more common in men risk factors include, hypertension, atherosclerosis age >60
other causes: Vasculitides (Wegner’s) but tends to be painless,
- Aortitis: a complication of tertiary syphilis
What are some musculoskeletal causes of chest pain and how does it present itself?
- Induced or relieved by postural change
- Highly localised
- Reproduced by pressure
- Tietze’s Syndrome (a specific type of costochondritis)
- M>F, 20-30 years old
- Pain localised to costal cartilage, usually palpable (tender) nodularities
- Exacerbated by coughing, sneezing, motion
- Usually post-viral URTI
What are some neurological causes of chest pain and how do they present themselves?
- Herpes zoster (‘shingles’), which is usually accompanied by a blistering rash along with a dermatomal distribution – classically not passing the midline.
Nerve roots can become compressed or irritated by:
- vertebral body collapse (secondary to trauma or metastases),
- metastatic growth and invasion,
- infection (including discitis)
What are some other general causes of chest pain?
- Mastitis (pain localised to structures of the breast): infection
- Mastalgia (hormonally mediated breast pain)
- Gynaecomastia (often physiological, but can be pathological – caused by hormonal changes/problems / abuse, iatrogenic [e.g. H2 antagonists] or physiological [e.g. puberty].
- Cysts: usually benign or malignancy: doesn’t usually present with pain)
- can be related to anxiety / underlying psychological factors, usually accompanied by but not always with; headache, dizziness, low back pain, hyperventilation, fatigue (TATT), dysmenorrhoea, aggression
