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Chest Pain - Coggle Diagram
Chest Pain
Examination
Carry out a Cardiovascular examination
- Heart sounds (for murmurs or pericardial rub)
- Blood pressure in both arms (possible aortic dissection)
- Pulse rate and rhythm (shock and arrhythmias)
- Jugular venous pressure
- Carotid pulse
- Ankles (For oedema, indicating heart failure)
Chest wall examination
- Listen to lungs for signs of infection
- Measure the respiratory rate and carry out pulse oximetry
General appearance
- Pallor and sweating (shock)
Abdomen
- Tenderness (gallstones, pancreatitis or peptic ulceration)
Neck
- Check for localised tenderness and stiffness (Cervial spondylosis or osteoarthritis)
Legs
- Swelling or tenderness (DVT)
Skin
- Rashes (shingles) and bruising (rib fracture)
Temperature
- Raised, especially over 38.5 (infection, pericarditis or pancreatitis)
Investigations
- Other investigations may be appropriate depending on the suspected underlying cause
- Investigations in Primary care should not delay admission or referral to hospital
ECG
- This will look for signs of hypertrophy, arrhythmia, pulmonary embolism, stable angina and acute coronary syndrome (ACS)
Blood glucose, lipid profiles, Urea and Electrolytes level
- Review Cardiovascular risk profile
Full Blood Count
- Anaemia which may exacerbate stable angina
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Liver function tests and amylase
- Cholecystitis and pancreatitis
C-reactive protein and erythrocyte sedimentation rate (ESR)
- Infection or inflammation
Chest x-ray
- Signs of heart failure and pulmonary pathology
Pulmonary Causes
Pulmonary Embolism
- Symptoms: acute onset breathlessness, pleuritis chest pain (worse on inspiration), cough, haemoptysis and/or syncope.
- Signs: Tachypnoea >20 breaths per minute, tachycardia, mild pyrexia, signs of DVT
Pneumothorax or tension Pneumothorax
- Symptoms: Sudden onset pleuritic pain and breathlessness in people with or without tachycardia
- Sign: Reduced chest wall movements, reduced breath sounds, reduced focal fremitus and increased resonance of percussion note on affected side. Tension pneumothorax can result in rapid development of symptoms associated with tracheal deviation away from the pneumothorax, tachycardia and hypotension.
Community-acquired Pneumonia
- Symptoms: Cough and at least one symptom of sputum, wheeze, dyspnoea or pleuritic chest pain.
- Signs: Focal chest signs (such as dull percussion note, broncial breathing, coarse crackles, or increased vocal frematis or resonance) plus at least one systemic feature (Such as fever or sweating, myalgia), with or without a temperature greater than 38.
Asthma
- Symtoms: wheeze, breathlessness, cough. Symtpoms are variable (often worse at night, first thing in the morning and upon exercise or exposure to cold or allergens).
- Signs: May be none when person is feeling well. During an acute episode, the respiratory rate is increased and wheeze normally present.
Lung or Lober Collapse
- Symptoms: Localised chest pain, breathlessness, cough.
- Signs: Reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds.
Lung Cancer
- Symptoms: chest or shoulder pain, haemoptysis, dyspnoea, weight loss, appetite loss, hoarseness and cough.
- Signs: finger clubbing, cervical or supraclavicular lymphadenophathy or thrombocytosis.
Pleural effusion
- Symptoms: Localized chest pain and progressive breathlessness.
- Signs: reduced chest wall movements on the affected side, stony dull percussion note, diminished or absent breath sounds, and (in people with heart on renal failure) signs of fluid overload.
History
Assess pain currently
- If no pain at present, find out when last pain in particular if within the last 12 hours
Carry out assessment of pain using SOCRATES
- Site
- Onset
- Character
- Radiation
- Associated symptoms
- Timing
- Exacerbating or relieving factors
- Severity
- Acute onset, with central or band-like pain radiating to jaw, arms, or back is suggestive of cardiac chest pain
- Persistent localised pain is suggestive of pulmonary/musculoskeletal causes
- Chest pain related to exertion is typical of angina
- Chest pain related to inspiration (pleuritic) may suggest musculoskeletal or pulmonary cause
- Breathlessness can be seen with cardiac/pulmonary cause
- Chest pain associated with palpitations, dizziness or difficulty swallowing is less likely to be angina.
Obtain a history of chest pain and if any previous investigations carried out.
Stable angina or MI: Assess for cardiovascular risk factors as these increase the likelihood of significant coronary artery disease
Respiratory and gastroenterological disease, MSK problems and previous trauma - common causes which are often overlooked
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Cardiac Causes
Acute Coronary Syndrome
- Suspect if:
- Pain in the chest or other areas lasts longer than 15 minutes.
- Chest pain is: Dull, central or crushing.
- Associated nausea with vomitting, sweating or breathlessness or combination.
- Haemodynamic instability.
- New onset, or abrupt deterioration of stable angina.
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Dissecting thoracic aneurysm
- Symptoms: Sudden tearing chest pain radiating to the back and inter-scapular region.
- Signs: High BP, BP different both arms, inequality in pulses (carotid, radial, femoral), a new diastolic murmur (aortic valve regurgitation), occassionally pericardial friction rub. Neurological deficits may be present.
Pericarditis/ Cardiac Tamponade
- Symptoms: Sharp, constant sternal pain relieved by sitting forward. Pain may radiate to left shoulder and/or left arm and/or into abdomen, and is worse when lying on the left side and on inspiration, swallowing and coughing. Fever, cough, arthralgia. Cardiac tamponade may have associated breathlessness, dysphagia, cough and hoarseness.
- Signs: Pericardial friction rub (High pitched scratching sound, best heard over the left sternal border during expiration). Signs of cardiac tamponade include pulsus paradoxus, hypotension, muffled heart sounds, and jugular venous distention.
Acute Congestive Cardiac Failure
- Symtpoms: Ankle swelling, tiredness, severe breathlessness, orthopnea, coughing (rarely producing frothy, blood-stained sputum).
- Signs: elevated jugular venous pressure, gallop rhythm, inspiratory crackles at lung bases and (often) wheeze.
Arrhythmias
- Symptoms: chest pain associated with palpitations, breathlessness and syncope (or near syncope)
- Signs: Bradycardia or tachycardia
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Other Causes
Gastrointestinal
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Peptic ulcer disease, gastro-oesophageal reflux, oesophageal spasm or oesphagitis
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Definition: Chest pain refers to pain in the thorax. It is commonly classified into cardiac or non-cardiac causes.