Week 2 - Chest pain

Question 1

Mr. Ben B, 55 year old man from Innisfail, brought in by his wife Enid, following an episode of anterior chest pain yesterday and another brief episode this morning.

Take a history of this patient.

HPC:
• Ben had the “flu” 3 days ago, fever, chills, headache.
• Last night, while watching TV - dull pain in the middle of the chest, tightness in throat, took “Mylanta”, did not help. Pain settled - 1 hr.
• Pain returned this morning in the shower, severe, sweating, scared, ambulance, pain almost settled, but still niggling (anxiety).
• Clinical features and types of angina? (stable vs. unstable).
• Pain constant, did not vary with breathing (what if it did?). Not related to eating?
• Past history: hypertension, DM2, dyslipidaemia and obesity (all related to his condition).
• Did not take aspirin for couple of weeks (why are people put on long term aspirin?). Did not take flu shot (what is relation of flu to chest pain?).

Answer 1

Age, gender, weight (i.e. obese)?

HPC:
• Site of pain?
• Onset of pain?
• Character of pain? i.e. sharp, dull, tearing, pleuritic.
• Does the pain radiate? i.e. arm, neck, back.
• Alleviating factors?
• Experienced it before? Constant or intermittent?
• Exacerbating factors?
• Severity?
• Associated symptoms? i.e. dyspnoea, sweating, palpitations, nausea, anxiety?
• Effect on lifestyle?

• Pain related to food? heartburn?
• Recent trauma, muscular injury or pain related to specific movement?
• Cough, haemoptysis, swelling/pain in legs?
• Fever, chills?
• History of depression, anxiety?

PMHx:
• Past history of cardiovascular disease, hypertension, diabetes, dyslipidaemia etc?
• Previous angina/MI?

PSHx:
• Any past surgeries?

Medications:
• Any regular medications e.g. aspirin, statin, nitroglycerin?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, pneumococcal?

FHx:
• Family history of IHD, diabetes, cancer etc?

SHx:
• Background?
• Occupation?
• Education?
• Religion?
• Living arrangements?
• Smoking?
• Nutrition?
• Alcohol/recreational drugs? i.e. cocaine.
• Physical activity?

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands. Patient 45˚, chest exposed.
2. General inspection: unwell/distressed, diaphoretic, anxious, restless, dyspnoeic, obese, signs of cyanosis.

3. Vital signs:
• HR - may be tachycardic, bradycardic, AF, VT, heart block (rate, rhythm, volume, radial radial delay).
• RR - tachypnoeic.
• BP - hyper/hypotensive.
• Temp
• O2 sats, BSL, BMI.

4. Hands:
• Warm/cool, dry/sweaty.
• Peripheral cyanosis, pallor.
• CRT.
• Xanthomata.

5. Face:
   • Eyes - conjunctival pallor, xanthelasma.
   • Mouth - peripheral/central cyanosis.
6. Neck:
   • Carotids - volume/character.
   • JVP (may be raised).
7. Praecordium:
   • Inspection - scars, abnormal pulsations, pacemaker, prominent veins.
   • Palpation - apex beat (dyskinetic), heaves, thrills.
   • Auscultation - heart sounds S3, S4, decreased intensity heart sounds, pericardial friction rub, transient apical mid systolic or late systolic murmur.
8. Back:
   • Inspection - scars, deformity.
   • Percussion - chest resonant.
   • Auscultation - equal air entry, normal vesicular breath sounds on both side, no added sounds.
9. Abdomen:
   • Inspection - scars etc.
   • Soft, non-tender abdomen, no masses, no organomegaly.

10. Legs:
• Peripheral cyanosis.
• CRT.
• Peripheral pulses.
• Oedema.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: ACS (unstable angina, MI).
• DDx:
- Coronary vasospasm (variant angina) - including cocaine/amphetamine use etc.).
- Hypertrophic cardiomyopathy (can give rise to ischaemia).
- Aortic dissection, aneurysm.
- Acute pericarditis.
- Pulmonary embolism.
- Musculoskeletal/neuropathic pain.
- Oesophageal: reflux (excess acid) and spasm.
- Pneumonia/pleurisy, pneumothorax.
- Perforated peptic ulcer.
- Acute biliary disease (cholecystitis) and pancreatitis.
- Panic disorder/psychological (can produce any symptoms).

Question 4

What investigations would you carry out on this patient?

Answer 4

• ECG.
• FBC, U+Es, BSL, coagulation studies.
• Cardiac enzymes - troponins.
• CXR.

Question 5

What treatment does this patient require?

Answer 5

• Admit to CCU and monitor in hospital.
• Adequate analgesia - IV morphine and antiemetic (metoclopramide).
• Monitor oxygen saturation - offer supplemental oxygen if oxygen saturation less than 95%.
• GTN - routine use now not recommended in acute setting unless patient is hypertensive or in acute LVF. Useful as anti-anginas in chronic/stable patients.
• Aspirin 300mg PO.
• Repeat ECG recordings can also be valuable - important when the diagnosis is uncertain or the patient has recurrent or persistent symptoms.
• Plasma troponin concentrations repeated 6-12 hours after the onset of symptoms or hospital admission.