Chest Pain Histories

Question 1

What is a history for angina?

SOCRATES

Answer 1

S - sternum
O - slow/insidious
C - sharp/stabbing
R - left shoulder/arm, jaw, tongue, teeth 
A - SOB? Autonomic upset? 
T - seconds to hours
E - triggers: exercsie, heavy meals, body position, cold weather
Relief: rest 
S - changes

Question 2

What is the diference between stable and unstable angina? (2)

Answer 2

• No specific trigger for symptoms = at rest

- Longer than 20 mins

Question 3

How can stable angina lead to unstable angina?

Answer 3

Unstable: detoriation of stable angina at lower level activity/rest

Question 4

Describe the presentation of unstable angina? History + investigations (4)

Answer 4

• SOCRATES of stable angina
• No STEMI changes (ST segment depression?)
• No cardiac biomarkers
• Some relief by GTN

Question 5

Describe the presentation of myocardial infarction? History + investigations (3)

Answer 5

• SOCRATES of stable angina
• ECG changes
• Cardiac biomarkers (troponin T/troponin I/creatine kinase)

Question 6

How does AF present? (4)

Answer 6

• Palpitations
• Chest pain
• Dyspnoea
• Dizziness / syncope

Question 7

What is severity of pain useful for in a chest pain history?

Answer 7

Assessing treatment impact

Question 8

What is an ischaemic chest pain like?

Answer 8

Crushing, band around chest

Question 9

What is a pleuritc chest pain like? (2)

Answer 9

• Stabbing/sharp

- Worse on inspiration

Question 10

What are the 2 types of chest pain?

Answer 10

• Pleuritic

- Ischaemic

Question 11

What questions should be asked when taking a chest pain history? (4)

Answer 11

• SOCRATES
• Chest pain history (first episode? frequency? Trigger? Investigations?)
• Other medical problems - cardiac risk factors?
• Family history

Question 12

What medical problems are associated with cardiac risk factors? (4)

Answer 12

• Diabetes
• Hypertension
• Hypercholesterolaemia
• Ischaemic heart disease

Question 13

What is the difference between stable angina and ACS? (6)

Answer 13

• Slow/insidious vs sudden
• Trigger vs at rest
• Greater pain
• SA= no heart damage vs ACS = heart damage
• SA=stable coronary artery plaque vs ACS = Rupture/erosion of the fibrous cap of a coronary artery plaque
• SA=relieved within 5 mins of rest/GTN spray vs ACS=not

Question 14

How does a PE present? (11)

Answer 14

• Breathlessness
• Chest pain (normally pleuritic)
• Haemoptysis (coughing up blood)
• Syncope/pre-syncope
• Fever
• Unilateral leg swelling (ass. DVT)
• Palpitations
• Tachycardia
• Tacypnoea
• Hypotension
• Hypoxia
• R side strain
• Rare: pleural rub (pleurisy)

Question 15

How does pericarditus present? (6)

Answer 15

• Worse on inspiration
• Worse lying down
• Relieved leaning forwards
• Sharp retrosternal pain
• Pleuritic rub in diastole
• Haematuria?

Question 16

GORD present (6)

Answer 16

• Burning/squeezing
• Radiating: epigastrium to throat (upwards)
• Relationship with food
• Relieved by antaacids
• Dysphagia/dyspepsia history
• Radiates to back : retrosternal

Question 17

Superficial MSK injury

Answer 17

• Local area of tenderness musculoskeletal pain
• Worse in particular postures/movement
• Reproduced by local palpitation

Question 18

PE risk factors (7) (SPASMODIT)

Answer 18

S - sex
P - Pregnancy
A - age
S - surgery
M - malignancy
O - oestrogen (pill/HRT)
D - DVT/PE
I - Immobility/infective endocarditus
T - Travel

Question 19

Aortic dissection (7)

Answer 19

• Sudden onset
• Tearing
• High intensity
• Radiates to the back between the shoulder blades
• Hypotension: collapse
• Tachycardia
• Profound anaemia

Question 20

General investigations for chest pain: bedside, bloods, radiology, CTPA, special. Give examples

Answer 20

BEDSIDE
- ECG
- Sputum culture (pneumonia)
BLOODS
- Troponin
- FBC (raised WCC in pneumonia)
- Blood culture (pneumonia)
- Lipids
RADIOLOGY
- Chest x-ray (pneumothorax, consolidation, pericardial effusion, aortic dissection)
- CTPA (PE)
- Calve doppler for DVT
SPECIAL TESTS
Upper GI endoscopy= acid reflux

Question 21

Costochonrditus (3)

Answer 21

• Arthritus history
• Well localised tenderness of costochonrdal junctions
• Exacerbated by local pressure

Question 22

Chest wall malignancy (5)

Answer 22

• Constant
• Unremitting
• Localised pain
• Unrelated to respiration
• Disturbs sleep

Question 23

What is atypical angina?

Answer 23

Only 2/3 of:

• Constricting chest pain
• Worse on exertion

Question 24

What investigation confirms diagnosis of stable angina?

Answer 24

CT angiogram

Question 25

NSTEMI vs STEMI

Answer 25

STEMI=ECG changes e.g new LBBB or ST elevation

Question 26

Unstable angina vs NSTEMI/STEMI (2)

Answer 26

UA: some GTN relief, others=no

NSTEMI/STEMI = more systemic upset

Question 27

Abdo causes of chest pain (6)

Answer 27

• Peptic ulcer
• Perforation
• Cholecystitis
• Pancreatitus
• Bilarly colic
• Oesophageal spasm

Question 28

Shingles (6)

Answer 28

• Sharp, band-like pain
• Strip across chest
• Fever
• Numbness, tingling
• Worse to touch/movement
• Fluid filled blisters not crossing midline rash several days later

Question 29

Infective endocarditus (7)

Answer 29

• Fever
• New heart murmer
• Petechiae (non blanching)
• Haematuria
• Rigors
• Night sweats
• HF
• Malaise

Question 30

Anaemia (3)

Answer 30

• Dizziness
• Chest pain
• Palpitations