Chest pain

Question 1

Presenting Complaint?

Answer 1

Open question - what has bought you in?

Question 2

HPC - list all things that you will ask in this section?

Answer 2

Have you had this before - what happened last time?
SOCRATES
Systemic review - cardio, resp, gastro (soecific to GORD)

Question 3

HPC - SOCRATES?

Answer 3

Site –where is the pain (e.g. central chest)

Onset:
When did it start?
What was the patient doing at the time of onset? (exertional / at rest)
Did it come on suddenly or has it been gradually building?

Character:
Aching / crushing –typical of acute coronary syndrome (ACS)
Sharp pain that’s worse on inspiration (pleuritic) – pulmonary embolus / pneumothorax

Radiation:
Left arm and jaw is typical of ACS + angina
Radiation through to the back is associated with aortic dissection

Associated features - any other symptoms

Timing - duration (angina vs acute coronary syndrome), particular times of day, progression [Worsening / improving / fluctuating]

Exacerbating/relieving factors

Severity

Question 4

HPC - Systems review for chest pain [what systems relevant]?

Answer 4

1. Cardio
2. Resp
3. Gastro {GORD}

Question 5

HPC - Systems review for chest pain - Cardio?

Answer 5

Chest pain
Nausea, vomitting and sweating (+chest pain) = ACS
SOB (exertional, orthopnoea, PND)
Palpitations - ask patients to tap out rhythm
Syncope/dizziness ( postural/exertional/random)
Ankle swelling

Note:
orthopnoea = sign of HF
PND - paroxysmal nocturnal dyspnoea refers to attacks of severe shortness of breath and coughing that generally occur at night. It usually awakens the person from sleep.

Question 6

HPC - Systems review for chest pain - Resp?

Answer 6

Chest pain:
Is it pleuritic [sharp pain worse on inspiration]

SOB

Cough
Is it productive

Haemoptysis

Wheeze

Question 7

HPC - Systems review for chest pain - GORD?

Answer 7

Chest pain worse after meals or lying down

Relieved with Gaviscon

Question 8

HPC - Systems review - general?

Answer 8

Malaise/lethargy
Weight loss/appatite change
Fever/night sweats
Rashes/Skin changes

Question 9

PMH?

Answer 9

Any other illnesses, hospital visits, surgeries
CANCER - always ask
o Diagnosis of angina
MIJTHREADS
[MI, Hypertension, Diabetes, Stroke]
o Additional Risk Factors: high cholesterol

Question 10

DH?

Answer 10

ALLERGIES –ensure to document these clearly
Regular prescribed medication?
Over the counter drugs
Herbalremedies
Contraceptive pill –increased risk of thromboembolic disease (e.g. PE)

Additional
Antiplatelets or anticoagulants?
GTN spray?

Question 11

Family history?

Answer 11

Cardiovascular disease in the family

[Ask age and cause of death]

Question 12

Social history?

Answer 12

o	IHD Risk Factors: smoking, alcohol, diet, exercise 
Recreational drugs (cocaine induced coronary artery spasm)

Note: Smoking – pack years = (packs per day - 20 in pack) x (years as a smoker)

2. Living situation [who they live with, carers, access e.g stairs]
3. Activities of daily living:
   Is the patient independent and able to fully care for themselves?
   Can they manage day to day activities self hygiene / housework / food shopping?
4. Occupation
5. Recent travel and pets

For cadio assess VTE Risk Factors: long haul travel, surgery, bedrest

Question 13

Differential diagnoses of chest pain - fatal 5?

Answer 13

o	FATAL FIVE
ACS
Aortic dissection
PE 
Pneumothorax 
Borehaave's perforation

Question 14

Differential diagnoses of chest pain - CV causes?

Answer 14

1. ACS: central, crushing, radiating to the arm/neck/jaw
   associated with SOB, nausea, vomitting and swetting.
   Duration of more than 20 minutes.
2. Stable angina: central chest pain, radiating to left arm /jaw
   Associated with SOB
   Duration less than 20 minutes with full resolution

Both ACS and stable angina improved by GTN and worse by exertion.

3. Pericarditis - central chest pain, Worsened by lying flat and improved by leaning forwards
4. Aortic Dissection – tearing pain between the shoulder blades (radiating to the back)

Question 15

Differential diagnoses of chest pain - resp causes?

Answer 15

1. Pneumonia: SOB + Sharp pleuritic chest pain [worsened by inspiration (pleuritic)]. Associated cough, fever and malaise
2. Pneumothorax – SOB + pleuritic pain
3. PE – SOB + pleuritic pain (ask about worsening of pain on inspiration) + leg swelling

Question 16

Differential diagnoses of chest pain - GASTRO causes?

Answer 16

Gastro-oesophageal reflux:
Epigastric / chest pain 
Burning in nature
Worsened by lying flat

Oesophageal spasm:
Epigastric / central chest pain
Relieved by GTN spray (hence can be confused with ACS)
but No association with shortness of breath

Question 17

Risk factors for DVT/PE

Answer 17

long haul travel, surgery, bedrest
Inherited coagulopathy (e.g. protein C or S deficiency)
Relevant medications (e.g. oral contraceptive pill / hormone replacement therapy)

Question 18

Risk factors for pneumothorax?

Answer 18

Tall, thin men in particular
Known connection tissue disease (e.g. Marfans)
Smoking history