Chest Pain

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Chest Pain

• Mudher Al-khairalla

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Jane presents to her GP with chest pain

• What would you like to know?

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Chest Pain

• Onset?
• Duration?
• Precipitating Factors?
• Relieving factors?
• Character?
• Site?
• Associations?
• Radiation?

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Chest Pain

• Onset?
• Duration?
• Precipitating Factors?
• Relieving factors?
• Character?
• Site?
• Associations?
• Radiation?

• Intermittent?

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Chest Pain

• Onset?
• Duration?
• Precipitating Factors?
• Relieving factors?
• Character?
• Site?
• Associations?
• Radiation?

6
Chest Pain

• Onset?
• Duration?
• Precipitating Factors?
• Relieving factors?
• Character?
• Site?
• Associations?
• Radiation?

• Emotion
• Exercise
• Food
• Weather
• Movement
• Cough
• Breathing
• Posture

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Chest Pain

• Onset?
• Duration?
• Precipitating Factors?
• Relieving factors?
• Character?
• Site?
• Associations?
• Radiation?

• Medicines
• Antianginal
• Antireflux
• Analgaesia
• Rest
• Posture

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Chest Pain

• Onset?
• Duration?
• Precipitating Factors?
• Relieving factors?
• Character?
• Site?
• Associations?
• Radiation?

• Sharp
• Heavy
• Tight
• Dull
• Gripping

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Chest Pain

• Onset?
• Duration?
• Precipitating Factors?
• Relieving factors?
• Character?
• Site?
• Associations?
• Radiation?

• Central
• Back
• Upper chest
• Side

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Chest Pain

• Onset?
• Duration?
• Precipitating Factors?
• Relieving factors?
• Character?
• Site?
• Associations?
• Radiation?

• Nausea
• Vomiting
• Sweating
• Presyncope
• Breathlessness
• Palpitations
• Ankle oedema

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Chest Pain

• Onset?
• Duration?
• Precipitating Factors?
• Relieving factors?
• Character?
• Site?
• Associations?
• Radiation?

• Jaw
• Arm(s)
• Back
• Epigastrium

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Which system might be responsible for Janes
chest pain?
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Systems

• Cardiac
• Respiratory
• Gastrointestinal
• Musculoskeletal

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Systems

• Cardiac
• Respiratory
• Gastrointestinal
• Musculoskeletal

• Central
• Heavy/Dull
• Radiates to jaw/arms/back
• Autonomic symptoms
• Exertional
• Relieved by GTN

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Systems

• Cardiac
• Respiratory
• Gastrointestinal
• Musculoskeletal

• Worse on inspiration and coughing suggests
  pleural irritation.
• Dull discomfort may suggest soft tissue mass,
  pleural mass or local invasion.

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Systems

• Cardiac
• Respiratory
• Gastrointestinal
• Musculoskeletal

• Indigestion
• Heartburn
• Spasms difficult to differentiate from cardiac
• Relation to posture and food

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Systems

• Cardiac
• Respiratory
• Gastrointestinal
• Musculoskeletal

• History of trauma
• Worse on breathing, movement and touch

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Jane is 31 and suffers from systemic lupus
erythematosis (SLE). She presents with left sided
chest pain which is worse on inspiration and
coughing. Movement or touch does not worsen the
pain.
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What type of pain does she have?

1. Cardiac
2. Pericardial
3. Musculoskeletal
4. Pleuritic
5. Oesophageal

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What type of pain does she have?

1. Cardiac
2. Pericardial
3. Musculoskeletal
4. Pleuritic
5. Oesophageal

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She tells you that the pain came on suddenly
earlier this morning and that she felt light
headed and breathless with it. There was no
sputum or fever
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What diagnosis should you consider?

1. Myocardial Infarction
2. Angina
3. Pneumonia
4. Costochondritis
5. Pulmonary Embolism

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What diagnosis should you consider?

1. Myocardial Infarction
2. Angina
3. Pneumonia
4. Costochondritis
5. Pulmonary Embolism

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John is 26 he presents to you with central chest
pain. He has never smoked, has no family history
of IHD and suffers from no medical illness.He
recalls helping a friend move furniture two days
ago
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What diagnosis is most likely?

1. Musculoskeletal
2. Pleurisy
3. Acute Coronary Syndrome
4. GORD
5. Pneumothorax

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What diagnosis is most likely?

1. Musculoskeletal
2. Pleurisy
3. Acute Coronary Syndrome
4. GORD
5. Pneumothorax

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He tells you that his pain is central, sharp in
character and worsens when he lies down flat
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This is his ECG
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www.postgradmed.com/issues/2004/03_04/ross.htm
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The diagnosis is

1. Pericarditis
2. Pneumonia
3. Atrial fibrillation
4. Pulmonary Embolism
5. Wolf Parkinson White type B

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The diagnosis is

1. Pericarditis
2. Pneumonia
3. Atrial fibrillation
4. Pulmonary Embolism
5. Wolf Parkinson White type B

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John is 58. He is a smoker who presents to his GP
with central chest pain. He is overweight and has
suffered from heartburn and indigestion for a
number of years. His pain can be brought on by
stress, heavy meals and exercise.
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What could be causing his pain?

1. Angina
2. Myocardial Infarction
3. GORD
4. Oesophageal spasms
5. Pericarditis

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What could be causing his pain?

1. Angina
2. Myocardial Infarction
3. GORD
4. Oesophageal spasms
5. Pericarditis

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His 12 lead ECG is normal
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What would you like to do next?

1. Trial of proton pump inhibitor
2. Oesophageal manometry
3. Gastroscopy
4. Exercise Tolerance Test (ETT) (Treadmill)
5. Coronary Angiogram

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What would you like to do next?

1. Trial of proton pump inhibitor
2. Oesophageal manometry
3. Gastroscopy
4. Exercise Tolerance Test (ETT) (Treadmill)
5. Coronary Angiogram

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Michael is 61. He is a life long smoker and had
worked in the shipyards in the past. He presents
with mild chest ache that has occurred
insidiously associated with breathlessness and
weight loss
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Examination reveals reduced breath sounds,
percussion note and vocal resonance over the left
lung
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Which of the following diagnosis is likely?

1. Benign asbestos disease
2. Mesothelioma
3. Lymphoma
4. TB
5. Pneumonia

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Which of the following diagnosis is likely?

1. Benign asbestos disease
2. Mesothelioma
3. Lymphoma
4. TB
5. Pneumonia

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End