Pleuritic Chest Pain

Question 1

Give some differentials for chest pain

Answer 1

Cardiac - ischaemic (e.g. acute coronary syndrome, stable angina, Prinzmetal’s angina, hypertrophic cardiomyopathy), non-ischaemic (aortic dissection, arrhythmias, pericarditis)​

Respiratory (pneumothorax (including tension pneumothorax), pulmonary embolism, pneumonia, pleurisy, lung cancer)​

Musculoskeletal (costochondritis, Tietze’s syndrome, trauma, rib pain (#, bony mets, osteoporosis), radicular pain​

Gastrointestinal (GORD, oesophageal rupture, oesophageal spasm, perforated peptic ulcer, cholecystitis, pancreatits, gastritis)​

Skin (herpes zoster infection)​

Psychological (anxiety, depression, panic disorder)​

Others (breast disease, sickle cell crisis, diabetic mononeuritis, tabes dorsalis)

Question 2

What is the innervation of the 2 layers of pleura and what are they sensitive to?

Answer 2

Parietal pleura​:
Nerve supply (intercostal nerves, phrenic nerve)​.
Sensitive to pain, pressure, touch and temperature​

Visceral pleura​:
Nerve supply (autonomic nerves supplying lung)​.
Sensitive to stretch

Question 3

Describe pleuritic chest pain

Answer 3

Pleuritic pain: ’sharp’, ‘knife-like’, ‘stabbing’, ‘catching’ pain that worsens with inspiration and expiration, well localised​

Question 4

What are the risk factors for a primary spontaneous pneumothorax?

Answer 4

• Smoking (22x for men, 9x for women)​
• Tall stature​
• Presence of apical subpleural blebs​
• Family history​
• 30% recur

Question 5

What are the risk factors for a secondary spontaneous pneumothorax?

Answer 5

COPD (60%), TB, Asthma, Malignancy, Fibrotic/Cystic lung disease

Question 6

What are the signs of a tension pneumothorax?

Answer 6

• Respiratory distress​
• ↓ ipsilateral breath sounds​
• Ipsilateral hyper-resonance​
• Tachycardia​
• Hypotension​
• Tracheal deviation, displaced apex beat​
• Immediate decompression essential

Question 7

What are the three components of Virchow’s triad?

Answer 7

1) Endothelial injury
2) Turbulent blood flow
3) Hypercoaguability

Question 8

What investigations would you do for a PE?

Answer 8

- ECG:​
Often normal​
Sinus tachycardia​
Signs of right heart strain (T wave inversion in V1-V3, RBBB, right axis deviation)​
S1T3Q3

• CXR – pulmonary infarction 10%PE, wedge shaped​
• D-Dimer​
• CTPA
• Also assess Well’s score

Question 9

Describe pericarditis

Answer 9

Pleuritic pain​
Central​
Relieved by sitting forward​
May be associated with fever

Question 10

What are some causes of pericarditis?

Answer 10

• Infection​:
  Viral (Coxsackie, echoviruses, influenza viruses, adenoviruses, mumps, HIV)​
  Bacterial ​
  Tuberculosis​
• Post-myocardial infarction (acute pericarditis, Dressler’s syndrome)​
• Trauma (cardiac surgery, stab wounds)​
• Inflammatory conditions (rheumatoid arthritis, SLE)​
• Uraemic ​
• Iatrogenic (drugs, radiotherapy)​
• Neoplastic (metastatic)

Question 11

What might you see on an ECG in pericarditis?

Answer 11

• Saddle-shaped ST segment elevation throughout most leads​
• PR depression​
• ST elevation persists

Question 12

What might you see on CXR in pericarditis?

Answer 12

Likely normal CXR in uncomplicated pericarditis​

Pericardial effusion​:

• Increased CTR​
• Globular or ‘flask-shaped’ - very large pericardial effusion

Question 13

How does community-acquired pneumonia present?

Answer 13

Cough, SOB, pleuritic chest pain, mucopurulent sputum, myalgia, fever​
Confusion/deterioration of pre-existing conditions

Confusion​
Urea >7 mmol/L​
Respiratory rate ≥ 30/min​
Blood pressure (systolic <90 or diastolic ≤ 60 mmHg)​
≥65 years of age

Question 14

What are some causes of transudate pleural effusion?

Answer 14

• Cardiac failure
• Renal failure
• Cirrhotic liver disease

Question 15

What are some causes of exudate pleural effusion?

Answer 15

• Parapneumonic
• Malignancy
• PE (10% transudates)
• Empyema
• Autoimmune