Chest Pain Common

Question 1

What are the symptoms of stable angina?

Answer 1

Chest discomfort by exertion, relieved by rest or nitroglycerine.
No change in intensity, frequency or duration.
No associated diaphoresis (sweating), nausea/vomiting or SOB
Known history of coronary artery disease

Question 2

What are the risk factors for stable angina? (8)

Answer 2

Age (men >45, women >55)
Positive family history of coronary artery disease
Hypertension 
Hyperlipidaemia
Diabetes
Smoking 
Stroke 
Peripheral Arterial Disease

Question 3

What are the signs of stable angina?

Answer 3

No specific findings, may have abnormal pulses if peripheral arterial disease present.

Question 4

What are the first line investigations that you would carry out on someone with stable angina?

Answer 4

ECG: no changes, previous infarction may be present as Q waves
CXR: normal or cardiomegaly
Cardiac Biomarkers: not elevated

Question 5

What are other investigations that you would consider doing in stable angina?

Answer 5

Stress Testing: ST segment elevation or depression greater than 1mm during or after exercise
Coronary Angiography: evidence of coronary artery narrowing
CT Coronary Angiography: identification of stenosis

Question 6

What are the symptoms of acute coronary syndrome?

Answer 6

Central chest pain (squeezing or heaviness)
Occurs at rest or accelerating tempo (crescendo)
Radiation to jaw or upper extremities
Associated with nausea, vomiting, dyspnoea, dizziness, weakness
Women, older people (>75) and diabetics may present with atypical features like nausea or dyspnoea.

Question 7

What are the signs of acute coronary syndrome?

Answer 7

May be normal 
Jugular venous distension
S4 gallop
Mitral Regurgitation murmur
Bibasilar fine crackles 
Hypotensive 
Tachycardic, Bradycardic or hypoxic depending on severity of ischaemia.

Question 8

What are the first line investigations you would do on someone with ACS?

Answer 8

ECG: ST elevation (in two leads, >1mm) or new left bundle branch block means STEMI. ST depression or T wave inversion could mean NSTEMI or unstable angina
CXR: normal/ signs of heart failure such as increased alveolar markings
Cardiac Enzymes: elevated in STEMI and NSTEMI but not in unstable angina

Question 9

What are the other investigations that you would consider in ACS?

Answer 9

BNP
Coronary Angiography: STEMI: critical occlusion
NSTEMI/ unstable angina: narrowing of artery

Question 10

What are the symptoms in pneumonia?

Answer 10

Productive/ dry cough
Fever / Rigors
Pleuritic pain (sharp, localised, worse on breathing or movement)
SOB
Myalgias
Arthralgia
Recent history of travel or infectious exposures

Question 11

What are the signs present in pneumonia?

Answer 11

Dullness to percussion
Decreased breath sounds
Crackles (rales)
Wheezing
Bronchial breath sounds
Increased tactile fremitus observed on severe consolidation

Question 12

What are the first line investigations you would so on someone with pneumonia?

Answer 12

CXR: Pulmonary infiltration, air bronchograms, pleural effusion

Question 13

What are the other investigations you would consider in someone with pneumonia?

Answer 13

WBC count: elevated with increased neutrophils
Sputum Culture: may reveal causative organism
Blood Culture: may reveal causative organism

Question 14

What are the symptoms in viral pleuritis?

Answer 14

Prodome viral illness (myalgia, malaise, rhinorrhoea, cough, nasal congestion, low grade temperature)
Contract with others having infectious disease.

Question 15

What are the signs of viral pleuritis?

Answer 15

Pleural friction rub (abnormal lung sound caused by inflamed pleura rubbing together)
+/- low-grade fever
sometimes tenderness to palpation of chest

Question 16

What are the first line investigations you would do on someone with viral pleuritis?

Answer 16

CXR: usually normal but can uncommonly have effusion

Question 17

What are the other investigations you would consider on someone with viral pleuritis?

Answer 17

FBC: normal or increased WCC with increased lymphocytes

Question 18

What are the symptoms of GORD?

Answer 18

Burning chest pain typically retrosternal which occurs when eating large or fatty meals
Pain can be reproduced when lying supine
Pain relieved by sitting up, antacids

Question 19

What are the signs in GORD?

Answer 19

None

Question 20

What are the first line investigations you would do in someone with GORD?

Answer 20

Therapeutic Trial: relief of symptoms with short trail of proton pump inhibitor- exclude cardiac cause before doing this

Question 21

What are other investigations that you would consider in GORD?

Answer 21

Oesophagogastroduodenoscopy: oesophageal inflammation or erosiosn

Question 22

What are the symptoms of costochondritis?

Answer 22

Focal chest wall pain
May have known precipitating injury
Pain aggravated by sneezing, coughing, deep inspiration or twisting of the chest

Question 23

What are the signs in costochondritis?

Answer 23

reproducible pain on chest wall palpation especially the costochondral junctions.

Question 24

What is the first line investigation that you would do in costochondritis?

Answer 24

CXR: no specific findings

Question 25

What are the symptoms of anxiety/ panic disorder?

Answer 25

Sharp chest pain 
Dizziness or faintness
Palpitations
Sweating 
Trembling or Shaking 
Fear of dying or going insane 
Paraesthesia (pins and needles)
Chills or hot flushes
Breathlessness or choking sensation

Question 26

What are the signs of anxiety or panic disorder?

Answer 26

Hyperventilation otherwise normal

Question 27

What are the first line investigations for anxiety or panic disorder?

Answer 27

ECG: normal

Question 28

What are the other investigations you would consider doing for anxiety or panic disorder?

Answer 28

CXR: normal

HADS (hospital anxiety and depression scale) score: may have a score >11