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Chest pain (Aetiology (Heart Vascular: ACS, angina, valve disease,…
Chest pain
Aetiology
Heart
Vascular:
ACS, angina, valve disease, arrhythmias
Infection:
pericarditis, myocarditis, tamponade
Trauma
: penetrating/blunt trauma, aneurysm, dissection
Congenital:
HCM
Degenerative:
valve disease
Lung
Vascular:
PE
Infection:
pneumonia, viral pleuritis, effusion, empyema
Trauma:
pneumothorax, diaphragm rupture
Neoplastic:
lung ca
Gastrointestinal
Infection/inflamm:
oesophagitis, gastritis, pancreatitis, cholecystitis, peptic ulcer
Trauma:
perf oseophagus
Idiopathic:
GORD, oesophageal spasm
Neoplastic:
oesophageal ca, gastric ca, pancreatic ca
Systemic
Metabolic:
electrolyte disturbance, anaemia
Endocrine:
thyrotoxicosis
Psychological:
anxiety/panic, somatoform, psychosomatic
Muloskeletal
Infection/inflamm: costochondritis, Herpes Zoster
Diagnosis
History
PC/HPC
Radiation
Shoulder, neck/jaw, arm(s) - MI
Interscapular, retrosternal - dissection
Retrosternal - GORD
Back - pancreatitis
Associated symptoms
SOB:
MI, PE, pneumonia, anxiety
Sweating:
MI
N&V:
MI
Palpitations
arrhythmia, valve disease
Dizziness/LOC:
ACS, arrhythmia
Cough:
PE, pnumonia
Haemoptysis:
PE
Haematemesis:
oesophageal rupture
Dysphagia:
GORD
Fever:-
penumonia, empyema
Chest wall tenderness:
costochondritis
Skin lesions:
shingles
Timing
Constant, intermittent
Worsening, improving
Character
Sharp/stabbing - pleuritis, pericarditis, dissection
Tight/gripping - angina. MI
Dull/aching/crushing - MI
Tearing - aortic dissection
Pleuritic (worse on inspiration) - pleuritis
Burning - GORD
Exacerbating/relieving factors
Exacerbating:
food (GORD, gastric ulcer); lying flat (GORD); chest palpation (musculoskeletal), exercise (MI)
Relieving:
food (duodenal ulcer); GTN/rest (MI, angina);
leaning forwards (pericarditis)
Onset
Sudden (vascular, trauma), insidious
Site
Central, Bilateral, Unilateral
DH
Current meds (NSAIDs), allergies
PMH
CVD, DM, HTN etc.
Lung disease
SH
Living arrangements, occupation,
smoking, alcohol, drugs (cocaine - MI)
FH
Cardio disease, resp disease,
GIT, other diseases
Investigations
Bloods
ABG (if hypoxic), FBC (anaemia, infection), CRP (infection), U+E, LFTs (cholecystitis/pancreatitis), TFTs (arrhythmia), glucose, lipids, D-dimer (PE), troponins (ACS),
amylase (pericarditis), clotting, G&S, crossmatch
Imaging
CXR: dissection, pneumothorax,pneumonia, pleural effusion
CTPA: PE
CT angiography: dissection
CT abdomen: pancreatitis
ECHO: pericarditis, tamponade, valve disease
Bedside
Obs (HR, RR, sats, BP, fever)
ECG (ST elevation/depression, TWI, saddle ST elevation/PR depression, arrhythmia, tachycardia/bradycardia, electrical alternans)
Examination
Cardio exam
Reduced pulse/radial delay (dissection)
Displaced apex (cardiomegaly)
New murmurs (AS, MR, ACS)
Raised JVP (acute HF)
peripheral oedema (HF)
bibasal crackles (HF, pneumonia)
Resp exam
Displaced trachea (tension pneumo, collapse, large effusion)
Crackles (pneumonia, HF)
Reduced sounds (effusion, collapse, pneumothorax), Percussion change (effusion, collapse, pneumothorax)
Unilateral leg swelling/tenderness (PE)
Musculoskeletal
Features of CT disease (dissection)
Tender palpation (costochondritis)
Dermatomal rash (herpes zoster)
Abdo exam
Tenderness/rebound/guarding
Murphy's and Rosvig signs
Palpable mass
Management
Initial ABCDE
Definitive
Per cause
Epidemiology
5% ED visits, 2% GP visits
In AED, commonly atypical/non-serious (30%)
angina (20%), non-ACS cardiac (15%), non-PE lung (10%),
ACS (10%), other (10%), abdo (2%), PE (0.5%)
Link Title
Definition
Sensation of pain in the thorax