Station 2: Chest Pain
Angina versus ACS (unstable angina versus NSTEMI/STEMI)
Do you usually suffer from chest pain or is this new?
Have you ever been told you have angina? And if so are you on treatment for it?
Does this chest pain feel different from your usual angina pain? In what way does it feel different?
SOCRATES
Is the pain central, heavy/tight?
Does it radiate?
Do you get breathless/nauseous/vomit/sweaty with the pain?
When do you get the pain?
Does exercise/emotion/cold weather/eating a heavy meal bring the pain on? How far can you walk before you get the pain? Can you manage the stairs/incline?
Is it relieved by GTN spray/rest? How long does it take for pain to go away?
How long does the pain usually last? How often do you get the pain?
Is the pain becoming more frequent/lasting longer/more severe/coming on with less exercise?
Is the GTN spray no longer working so well?
Are you now getting pain on minimal exertion?
Are you getting pain at rest?
Does the pain stop when you stop exercising and return when you restart exercising?
If patient currently has pain ask timing questions (since when, sudden/gradual onset, is it getting worse, have they still got the pain now) and SOCRATES
Ask Cardiac Risk factors: cholesterol, hypertension, diabetes, smoking, family history
Ask PMH cardiac: Known cardiovascular problems? Eg. MI, TIA/stroke, peripheral vascular disease. Ever had ECG/exercise tolerance test/angiogram etc.?
Ask Fx cardiac problems/stroke etc. as above. At what age did they have these problems?
Systems review cardiac: palpitations, (pre)syncope, ankle swelling, SOB, orthopnoea, PND. Eg. associated heart failure
Pericarditis
Is the pain worse when you breathe in/cough/lie down?
Is it better when you sit up and lean forward?
Any infection recently? Fever?
Is it a sharp pain?
Any history or symptoms of chronic kidney disease (uraemia), cancer, TB, myxoedema, HIV, rheumatological conditions?
Aortic Dissection
Tearing pain? Sharp?
Through to the back?
Maximal pain at onset?
Weakness/sensory loss in arms/legs?
Known HT/connective tissue disorder/Fx aortic pathology.
Also consider myocarditis, coronary spasm, structural cause eg. HOCM, valve disease, arrhythmias
Respiratory cause of chest pain eg. pneumonia, pneumothorax, PE, asthma/COPD, lung cancer
Systems review respiratory:
Wheeze
Cough and sputum
Haemoptysis
Fever
SOB
Pain worse on inspiration/coughing?
Leg swelling/pain?
Ask Risk factors PE/DVT: surgery, pregnant, fractures, cancer, bedbound/recent illness limiting mobility, PMH DVT/PE, Fx DVT/PE, contraceptive pill/hormone replacement therapy, long flights, Fx/PMH clotting problem
Ask PMH: respiratory problems eg. COPD
Ask Fx: respiratory problems
Gastro cause of chest pain eg. GORD, oesophageal spasm/rupture, biliary, pancreatitis, peptic ulcer disease
Heartburn/indigestion symptoms eg. regurgitation
Burning pain?
Night time pain
Pain when lying flat
Pain after eating
Difficult/painful swallowing?
Belching
Nausea/vomiting
NSAIDs/alcohol/bisphosphonates
Pain relieved by antacids
Ask PMH gastro: Known to have reflux/peptic ulcers/gallstones? Ever had OGD?
Ask Fx gastro
Ask Systems review gastro eg. Abdo pain, weight loss, dysphagia
MSK eg. Costochondritis, sternoclavicular arthritis eg. in Rheumatoid arthritis/ankylosing spondylitis, cervical disc disease, rib fracture eg. due to trauma/osteoporosis, tietzes, fibromyalgia, lupus
Does it hurt when you move?
Is it painful to touch your chest?
Trauma?
Other joint problems eg pain and swelling, fatigue, low mood, neck/back/shoulder pain
Autoimmune conditions: mouth ulcers, hair loss, rash, raynauds. Proceed to take rheumatological history if symptoms sound suggestive of a rheumatological condition
Miscellaneous:
Rash on chest/tender chest wall (herpes zoster)
Anaemia
Anxiety/panic/domestic violence
Sickle cell disease causing rib infarct
Tumour eg. sarcoma/multiple myeloma or metastases involving ribs/soft tissue of chest wall
Thyroiditis
Sarcoidosis
Substance abuse eg. Cocaine
Muscle strain (do they go to the gym?)
Breast disease
PMH: cardiac/resp/gastro/MSK
Dx: cardiac meds, resp meds, gi meds eg. PPI. Drug causes of pericarditis.
Fx: cardiac eg. MI <55 yo, resp/gastro
Sx: occupation, drug use eg. cocaine, smoking, alcohol, impact on activities of daily living, driving, travel
Systems review
ICE
Examine: CVS, Resp, GI, MSK systems
Investigations as per most likely cause.
Examples:
BP, Capillary blood glucose
ECG
Troponin
CXR
Urine dip
Fbc, U+E, LFT, glucose/hba1c, lipid profile, TFTs, CRP, amylase
Exercise tolerance test
Myocardial perfusion scan
Echo, stress echo
Angiogram
Ddimer, CTPA
Abdo USS, OGD
References:
https://patient.info/doctor/chest-pain-pro