Chest pain in adults Flashcards
Probability diagnosis
Musculoskeletal (chest wall) incl. costochondritis
Psychogenic
Angina
Serious disorders not to be missed
Cardiovascular:
- myocardial infarction/unstable angina
- aortic dissection
- pulmonary embolism/infarction
Neoplasia/cancer:
- lung cancer
- tumours of spinal cord and meninges
Infection:
- pneumonia/pleuritis (pleurisy)
- mediastinitis
- pericarditis
- myocarditis
Pneumothorax
Pitfalls (often missed)
- Mitral valve prolapse
- Oesophageal spasm
- Gastro-oesophageal reflux
- Biliary colic
- Peptic ulcer
- Herpes zoster
- Fractured rib (e.g. cough fracture)
- Spinal dysfunction
- Precordial catch (‘stitch’ in side)
- Rarities:
- pancreatitis
- Bornholm disease (pleurodynia)
- cocaine inhalation (can ↑ ischaemia)
- hypertrophic cardiomyopathy
Masquerades checklist
Depression (possible)
Anaemia (indirect)
Spinal dysfunction
Is the patient trying to tell me something?
Consider functional causes, especially;
- anxiety with hyperventilation
- opioid dependency
Key history
This needs to be meticulous because of the life-threatening causes.
Analyse the pain into its usual characteristics with the SOCRATES system.
Note family, drug, psychosocial and past history, especially if immunocompromised (e.g. diabetes or metabolic syndrome).
Key examination
General appearance
Vital signs
Peripheral circulation
Careful examination of cardiovascular and respiratory systems
Upper abdominal palpation
Key investigations
Base tests available to the GP are
ECG
cardiac enzymes and
CXR and in most instances help confirm the diagnosis.
Otherwise specialist investigations including imaging are confined to hospitals and cardiology centres.
Diagnostic tips
Consider chest pain as due to a coronary syndrome until proved otherwise.
Hx remains the most important clinical factor in the diagnosis of ischaemic heart disease and other conditions.
With angina a vital clue is the reproducibility of the symptom.
Checkpoints and golden rules
Chest pain represents an ACS until proved otherwise
Immediate life-threatening causes of spontaneous chest pain:
- myocardial infarction
- pulmonary embolism
- aortic dissection
- tension pneumothorax
The main differential diagnoses of MI:
- angina
- aortic dissection
- pericarditis
- oesophageal reflux and spasm
- hyperventilation with anxiety
- Tako-Tsubo stress-related cardiomyopathy
History remains the most important clinical factor in diagnosis of ischaemic heart disease.
With angina a vital clue is reproducibility of the symptom.
Red flag pointers for acute chest pain
- Dizziness/syncope
- pain in arms L>R, jaw
- Thoracic back pain
- Sweating
- Palpitations
- Syncope
- Haemoptysis
- Dyspnoea
- Pain on inspiration
- Pallor
- Past history: ischaemia, diabetes, hypertension
Psychogenic chest pain
can occur anywhere in the chest
often it is located in the left submammary region, usually without radiation
It tends to be continuous and sharp or stabbing.
It may mimic angina but tends to last for hours or days.
It is usually aggravated by tiredness or emotional tension
may be associated with shortness of breath, fatigue and palpitations.
