Chest pain history Flashcards
What are the key differentials for chest pain?
- ACS
- Acute pericarditis
- PE
- Spontaneous Pneumothorax
What are they key features of ACS?
Characterised by sudden onset central chest pain which may radiate to the neck or left arm, and is often associated with breathlessness, nausea, and diaphoresis.
Risk factors which may be noted during the history include age, smoking history, and sedentary lifestyle.
How would you diagnose ACS?
Diagnosis requires 2/3 of the following:
- Classical cardiac chest pain
- Ischemic features on an ECG, e.g. pathological q-waves, ST depression or elevation, T wave inversion, new onset heart block
- Biochemical evidence of cardiac ischemia, e.g. high sensitivity troponins
What is the key features of acute pericarditis?
This classically presents with central chest pain which is aggravated on lying down and relieved by leaning forwards.
How would you diagnose acute pericarditis?
The diagnosis is often clinical, but can be supported by the following:
- ECG changes - PR depression, saddle ST elevation across the chest leads
- CXR - globular heart (if associated pericardial effusion)
- ECHO - if associated pericardial effusion
What are they key features of PE?
This is classically pleuritic chest pain, the location of which will vary depending on the site of the embolism and associated lung infarct.
It is typically accompanied by breathlessness and haemoptysis in late stages. Often, an accompanying lower limb DVT is present.
How would you diagnose PE?
- Pre-test probability assessment via Well’s PE score
- CTPA - indicated if Well’s score >4
- ECG - evidence of right heart strain such as inferior lead T-wave inversion, right axis deviation, right bundle branch block, and rarely the S1Q3T3 pattern (deep S waves in lead 1, Q waves in lead 3, T-wave inversion in lead 3)
- ABG - hypoxic respiratory failure, often accompanied with alkalaemia secondary to a respiratory alkalosis which is driven by hyperventilation
- CXR - rarely, wedge infarcts or regional oligemia distal to the site of embolism may be visible
What are key features of a spontaneous pneumothorax?
This can result in pleuritic chest pain, the location of which can vary. It is more common in tall, slim and young male adults and is accompanied with breathlessness.
A history of a connective tissue disease, such as Marfan’s syndrome, or previous history of chest wall trauma also make this diagnosis more likely.
How would you diagnose a spontaneous pneumothorax?
CXR
How would you approach asking about the presenting complaint in chest pain?
- Asks when the pain started
- Asks whether it is intermittent or continuous
- Asks if it is improving or progressively getting worse
- Asks about pain site
- Asks about pain onset
- Asks about pain character
- Asks about radiation of pain
- Asks for associated symptoms
- Asks for exacerbating and alleviating factors
- Asks about severity score out of 10
What questions would you ask in the systems review for chest pain?
Cardiovascular:
- Asks about palpitations
- Asks about exertional dyspnoea
- Asks about paroxysmal nocturnal dyspnoea
- Asks about orthopnoea
Respiratory:
- Asks about haemoptysis
- Asks about pleurisy
- Asks about leg swelling
- Asks about productive cough
Malignancy:
- Asks about fevers
- Asks about night sweats
- Asks about unintentional weight loss
Miscellaneous:
- Asks about heartburn
- Asks about reflux
- Asks about dyspepsia
- Asks about dysphagia and regurgitation
- Asks about trauma
- Asks about tenderness on palpation
What would you ask about social history?
- Asks about current living situation
- Asks about current employment
- Asks about smoking history
- Asks about alcohol consumption
- Asks about recreational drug use
- Asks about any recent travel
What would you worry about in women with chest pain?
PE, ask about long flights and birth control!
