Chest pain Flashcards
(22 cards)
Challenges
Common symptom
Any structure in chest can cause pain
Various causes - acute and life threatening
How common?
5% population experience ‘chest pain’ in any two week period
2% patients in GP present with ‘chest pain’ as a new symptom
30% hospital medical admissions have ‘chest pain’
Sources
Cardiac Pericardial Oesophageal Pleural Vascular Musculoskeletal Neurological Psychological
Acute life threatening causes
Myocardial ischaemia/infarction Massive pulmonary embolus (discussed on Monday) Ruptured aortic aneurysm Pericarditis Acute pneumothorax (discussed on Monday) Ruptured oesophagus (rare)
MI vs Angina
Similarities: Pain distribution Differences: Severity Frightening Lasts hours Not relieved by nitrates No precipitating cause Accompanied by pallor, sweating, vomiting
Cardiac Pain
Front of the chest, mid or upper sternum
Radiating to left arm, both arms, round the chest or into the jaw
Described as tight, heavy, constricting, crushing, numbing or burning
But can be atypical, e.g. in women and diabetics
Chest pain history
Onset
Site of pain
Quality and intensity
Pattern and duration
Exacerbating factors (eating, exercise, breathing, position or movement)
Associated symptoms (sweating, vomiting, cough, weight loss etc)
Relieving factors (position, medication)
Checklist for stable angina
- predictable
- related to exercise
- worse in cold or windy weather
- induced by stress
- relieved by nitrates
Examination
History
Get the basics right: Pulse, BP, Resp rate, temp, O2 sats
Document in notes
Thorough examination- palpate chest
An ECG may be important
Suspected MI treatment
Aspirin
GTN spray
Diamorphine
02 (if sats <96%)
ECG - basics
The P wave represents atrial depolarization.
The QRS complex represents ventricular depolarization.
The T wave represents ventricular repolarization.
Pericardial Pain
Mediastinal pain
May be referred to shoulder & back
Made worse by breathing, coughing & sneezing
Influenced by posture, typically relieved by sitting forward
Pericarditis causes
Viral infection
- in context of ‘flu like illness - Coxsackie virus, mumps, herpes, HIV
Post myocardial infarction
Pleuritic pain
Usually one sided
Worse on inspiration
‘Sharp’, ‘stabbing’ or ‘knife-like’
Severe
Mode of onset & associated symptoms gives clue to aetiology
Dyspnoea/Haemoptysis
Think of pneumonia, pulmonary embolism, pneumothorax and malignancy
Vascular causes of chest pain
Dissecting aortic aneurysm
Dissecting aortic aneurysm
Difficult to diagnose
Ways in which pain may differ from MI:
- more sudden onset - described as ‘tearing’ - moves from front to back as the dissection extends
Gastro-oesophageal reflux disease
Musculoskeletal pain
Trauma
Malignancy (e.g. lung)
Psychological: difficult to reassure people with chest pain
Commonest causes GP vs medical ward
GP surgery
- musculoskeletal
- angina
- oesophageal reflux
- anxiety
Medical ward
- pneumonia - myocardial infarction - pulmonary embolus
Gastro Oesophageal Reflux Disease (GORD)
Common Not dissimilar to cardiac pain Patients often suffer from both ‘Burning’ discomfort Induced by bending Acid, bitter taste in mouth Relieved by antacid (& sometimes nitrate) Improved by raising head of bed & stopping smoking
Musculoskeletal chest pain
Induced or relieved by postural change
Highly localised
Reproduced by pressure
Tietze’s Syndrome
Tietze’s Syndrome
M>F, 20-30 years old
Pain localised to costal cartilage
Exacerbated by coughing, sneezing, motion
Others causes: Dermatological/Neurological
Nerve root compression
- Collapsed vertebrae
- Bone metastasis
- Abscess
Shingles
