T1 L18: Chest pain

• What are some red flags?

  Sudden onset

  Triggers – exercise/activity

  Type of pain – dull ache, constant, sharp pleuritic pain

  Radiation – going to the jaw/left arm/back

  Associated symptoms – high fever, haemoptysis, dizziness, sweating/clammy

  Shortness of breath – severity of this

  Effect on ADLs

  Presence of risk factors

  Elderly

  PMHx – previous heart disease, immunocompromised etc.
• What risk factors would you want to ask about?

  • ICE – what is the patient worried about?
  • Social history – smoking, alcohol intake, drug abuse, occupation, obesity
  • Risk factors for cause – COCP use, travel history, recent operations, pregnancy Relevant past medical history - hypertension, diabetes, high cholesterol
  • Previous cardiac problems/MI
  • Drug history – aspirin, statins etc.
• How can 'case mix' (cohort) differ between healthcare settings?

  • Primary care – undifferentiated cases, access of investigations is limited, low likelihood of serious causes but you can get some serious causes coming through to GPs first
  • A&E / Secondary care – greater likelihood of more acute presentations, access to investigations
• What are some common and serious cases coming in with chest pain?

  • Common causes for chest pain – GORD, muscular pain
  • Serious causes – myocardial infarction, pulmonary embolism, aortic dissection etc
• What is Costochondritis?

  Tenderness of costochondral junctions of ribs or chondro-sternal joints of the anterior chest wall

  Caused by: inflammation

  Onset: Acute or gradual onset – sharp/aching/pressure

  Can be localized to costal cartilage

  Exacerbating: Made worse by movement, coughing, sneezing

  May be preceded by coughing or strenuous exercise

  Self-limiting condition – can take weeks/months

  Treatment: reassurance, pain relief, monitoring, safetynetting advice
• What is Shingles?

  caused by Herpes zoster

  Pain appears first followed by blistering rash along dermatomal distribution, usually unilateral

  • Pain character: tinging, sharp, pins and needles
  • Treatment: antiviral therapy

  
• What is the character of pain caused by Stable angina?

  dull ache

  brought on by exertion/stress, relieved by rest

  relieved completely by rest or GTN (nitroglycerin)

  radiation may be present
• What are the investigations done for stable angina?

  clinical history

  bloods (normal troponin)

  ECG - normal during episodes
• What is the management of stable angina?

  medication - GTN spray, beta blockers

  risk modifications

  referral - angiogram
• What is the pain character of unstable angina?

  dull ache

  brought on by exertion/stress

  constant, not relieved by GTN

  radiation may be present
• What are the investigations done for unstable angina?

  bloods - troponin (raised)

  ECG:

  • ST segment changes (depression / elevation),
  • T wave inversion
  • sinus tachycardia

  Chest X-ray
• What is the management for unstable angina?

  MONA: morphine, oxygen, nitroglycerin, aspirin

  Angiogram - stent insertion

  CABG

  risk modifications

  medications
• What is the pain character of pericarditis?

  sharp pain

  constant, can be relieved by sitting forward, worse on lying flat/inspiration/swallowing or coughing

  radiation may be present

  preceding symptoms of viral illness/underlying cause
• What are the investigations done for pericarditis?

  bloods

  • raised troponin
  • raised inflammatory markers

  ECG:

  • widespread saddle shaped elevation in ST segment

  Chest X-ray
• What is the management of pericarditis?

  anti-inflammatory medication / NSAIDs

  steroid therapy

  treatment of underlying disease
• What is the pain character of pulmonary embolism (PE)?

  sharp pleuritic pain

  worse on breathing/coughing

  sudden onset

  other symptoms: breathlessness, haemoptysis, calf pain and swelling, dizziness/light-headedness
• What are the investigations for pulmonary embolism?

  arterial blood gases (ABG): hypoxia

  Bloods: raised D-dimer (by-product of blood clotting)

  ECG: sinus tachycardia

  Chest x-ray

  Doppler ultrasound of calf

  CT pulmonary angiogram
• What is the management of pulmonary embolism?

  oxygen

  pain relief

  anticoagulation

  thrombolytic therapy
• What is the pain character of pneumonia?

  sharp/dull pain - pleuritic

  worse on breathing / coughing

  gradual onset

  other symptoms: coughing, sputum, haemoptysis, fever, breathlessness
• What are the investigations for pneumonia?

  clinical history and examination

  bloods: raised inflammatory features

  chest x-ray
• What is the management of pneumonia?

  oxygen relief if needed

  pain relief

  antibiotics
• What is the pain character of pleural effusion?

  sharp/dull pain or asymptomatic

  constant and worse on breathing

  gradual onset

  breathlessness, signs of underlying causes (lung cancer, heart failure etc)
• What are the investigations for pleural effusion?

  ABG

  bloods

  chest x-ray
• What is the management for pleural effusion?

  oxygen if needed

  pain relief

  chest drain

  treat complications

  treat underlying cause