Chest Pain

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FieldsGORD Acute Coronary Syndromes Boney Chest Pain Myocarditis Hypertrophic Cardiomyopathy Pnuemothorax Pneumonia Panic Attack Pericarditis Stable Angina Musculoskeletal Chest Pain Sickle Cell Crisis Pulmonary Emobilsm 
Age Increases with Age Increases with Age >50 years Mean age 40s Young Most common in 20-40y, also seen often in older patients Extremities of age Most common in 30s-40s, but can occurr at any age Increases with Age Increases with age. Typically >50, if high risk may be >30. All Ages All Ages Increases with age 
Gender M = F M > F M = F M = F M = F M > F M = F F > M M > F M > F F > M M = F  M, >55 M > F 
Typical Presentation An overweight 53 year old man with a 20 pack year smoking history, who drinks ~30 units of alcohol each week presents to his GP with ‘burning’ epigastric pain and an intermittent acidic taste at the back of his throat. He finds it hard to say if the pain is in his chest or epigastrium. He has a history of depression, for which he takes Imipramine. An obese 70 year old male with a 40 pack year smoking history and type 2 diabetes mellitus is brought to A&E with shortness of breath and central crushing chest pain which is radiating down the inside of his arm, and into his jaw. A 68 year old man with known prostate cancer presents to his GP complaining of lethargy, weight loss and chest pain which is not relieved by anything, and keeps him awake at night. He is constipated, and his mental state seems to have declined. His blood tests show raised serum alkaline phostphatase and hypercalcaemia. A 40 year old man with a PMH of rheumatoid arthritis develops chest pain, palpitations and dyspnoea. O/E he has a fever and is tachycardic. He suffered a viral illness recently. An 18 year old male athlete visits his GP with progressive chest pain and intolerance to exercise, which exacerbates his pain and causes SOB and palpitations. He has had several episodes of feeling very faint. Chest auscultation reveals a murmur which decreases upon asking the patient to stand. A 30 year old male smoker with cystic fibrosis presents to A&E with shortness of breath and sharp chest pain. On examination, there is asymmetric lung expansion, hyperresonance on percussion and decreased tactile vocal fremitus. His breath sounds were reduced on one side. Also classically seen in otherwise fit, young, tall men. A 75 year old woman receiving radiotherapy for oesophageal carcinoma becomes increasingly confused and develops shortness of breath, pleuritic chest pain and a dry cough. O/E she has a temperature of 39’C and she is tachypnoeaic and tachycardic. Chest auscultation suggests a pleural rub A 30 year old woman presents to A&E with shortness of breath, palpitations, chest pain and the belief that she is about to die. O/E she is sweating and trembling. She has a history of anxiety and depressionA 40 year old man who is known to have had a recent infection with coxsackie virus develops shortness of breath and sharp, pleuritic chest pain which is relieved by leaning forwards. He had rheumatic fever as a child. A 70 year old obese man of South Asian origin with known hyper-cholesterolaemia and a family history of cardiovascular disease visits his GP with recurrent tight chest pain which sometimes radiates to his arm or neck, and is brought on by exercise or going outside in the cold. It usually lasts for a few minutes and resolves with rest. A 30 year old woman with fibromyalgia presents to her GP with a 2 week history of dull aching chest pain with intermittent stabbing pain in the same area. This was preceded by a cough and a cold. She is otherwise well. A 20 year old African woman with known sickle cell disease presents to A&E with acute onset chest pain, and cough. O/E she is tachypnoeic and has a fever. A 35 year old woman who has recently undergone orthopaedic surgery presents to A&E with acute onset shortness of breath and haemoptysis. O/E she is hypotensive with a raised JVP. She takes no regular medications other than the COCP. 
Other Symptoms • Frequent ‘heartburn’. Worse after large meals, and at night / om lying down, particularly if soon after eating • Pain relieved by over the counter antacids • Regurgitation of food and acid • Acid brash • Waterbrash • Choking at night • Odynophagia or dysphagia if chronic • Nocturnal asthma/ chronic cough • Pain may be in chest, epigastrium, RUQ or back, or all of these! ● Central crushing chest pain ● May radiate down inside of arm and into neck/ jaw/ epigastrium/ back ●Nausea ●Feeling hot/clammy ● SOB ● Distress ● 'Feeling of impending doom' ● Syncope ● Vomiting ● Confusion ● Deterioration in mental status (hypercalcaemia) ● Depression ● Tenderness on palpation ● Chest pain ●Chills ● Dyspnoea ● Palpitations ● Syncope ● Chest pain ● SOB ● Fatigue ● Syncope ● Palpitations ● Sharp chest pain ● SOB ● Chest tightness ● Cough ● Fatigue ● Reduced AE on affected side ● SOB ● Cough (usually productive in young; dry in eldery) ● Vomiting ● Headache ● Loss of appetite ● Pleuritic chest pain ● Haemoptysis (rarely) ● SOB ● Palpitations ● Feeling of choking ● Chest pain ● Nausea● Dizziness ● Derealisation/ depersonalisation ● Feeling of impending doom ● Numbness/ tingling ● SOB ● Tight, heavy or gripping chest pain ● May radiate to the neck, jaw, arms or back ● ● Steady aching chest pain with intermittent stabbing pain ● May be exacerbated by deep breathing/ changes in position ● Chest pain ● Cough ● SOB ● Haemoptysis ● Dizziness ● Syncope 
Pain • Sudden onset dull/ burning epigastric and retrosternal pain. Acute, sudden onset Chronic Subacute onset Acute / sub-acute chest pain on exertion, in otherwise young fit person Acute, worse in inspiration ('pleuritic') Sub acute onset. Pleuritic. Acute onset. Can be described as central and crushing, like ACS. ● Acute ● Sharp, pleuritic chest pain aggravated by movement, exercise and swallowing and relieved by leaning forwards Acute onset on exertion. Resolves with rest. Classically worse in cold weather Can be acute, suc-acute or chronic. Chest dfor hx of trauma, exercise, activity that could have caused pain. Chest wall tenderness Acute Pleuritic, acute onset, ften felt in the back, less often in the chest 
Signs • Laryngitis (hoarse voice) • Overweight ● Sweating ● Tachycardia ● 3rd/4th heart sounds ● Pan systolic murmur ● Pericardial rub ● Pulmonary oedema (crepitations in lungs) ● Hypotension ● Quiet first heart sound ● Narrow pulse pressure ● Raised JVP ● Pallor ● Constant chest pain present at rest and at night ● Weight loss ● Night sweats Fatigue ● Constipation ● Fever ● Sweating ● Tachycardia ● Gallop rhythm ● Mitral regurgitation ● Peripheral oedema ● Lymphadenopathy ● Skin rash ● Heart murmur on auscultation which decreases upon standing/ Valsalva maneuver ● Tachycardia ● Tachypnoea ● Cyanosis (skin blue etc.) ● Absent breath sounds over affected lung ● Asymmetric lung expansion – mediastinal and tracheal shift to contralateral side in tension pneumothorax ● Hyperresonance on percussion ● Decreased tactile fremitus ● Adventitious lung sounds: ipsilateral crackles, wheezes ● Tracheal deviation (tension pneumothorax - decompress immediately!) ● Fever ● Rigors ● Upper abdominal tenderness if lower lobe pneumonia ● Signs of consolidation ● Dyspnoea ● Tachypnoea ● Tachycardia ● Increased secretions in ventilated patients ● Pleural rub/ rapid shallow breathing (if strep pnuemoniae) ● Confusion in elderly ● Hypotension and AF are complications ● Sweating ● Trembling or shaking ● Cold peripheries ● Fever ● Pericardial friction rub ● Positive Levine sign (patient’s fist clenched over sternum when describing the discomfort) ● Signs of abnormal lipid metabolism: xanthelasma, xanthoma ● Signs of diffuse atherosclerosis: diminished peripheral pulses, carotid bruit ● Localised tenderness on palpation ● Tender chest wall ● Wheeze ● Fever ● Tachypnoea ● Pyrexia ● Cyanosis ● Tachypnoea ● Tachycardia ● Hypotension ● Raised JVP ● Pleural rub ● Pleural effusion 
Past Medical History • Hiatus Hernia • Smoking • LOS Dysfunction • Alcohol • Fat/ caffeine/ chocolate consumption • ?Stress • Tricyclics/ anticholinergics/ nitrates • Systemic sclerosis ● FH IHD / MI ● Smoker ● Hypertension ● Diabetes ● Hyperlipidaemia ● Obesity ● Sedentary lifestyle ● Stress ● Left ventricular hypertrophy ● Cocaine use ● High fibrinogen levels ● Type ‘A’ personality ● IHD ● Previous MI ● HX cancer ● Smoker ● FH ● ● HX viral/ bacterial/ other illness ● Autoimmune inflammatory disease● Recently started taking new drug ● Penicillin, chloramphenicol, sulphonamides, antihypertensives, antiseizure drugs, amphetamines ● Radiation exposure ● Acute rheumatic fever ● Giant cell myocarditis ● SarcoidosisKawasaki disease ● IBD ● SLE ● FH ● Pain brought on by exercise/ meals ● Young athlete ● Angina ● Progressive exercise intolerance ● Arrhythmia ● Tall and thin ● Smoker ● FH ● Underlying lung disease (COPD, cystic fibrosis, pneumonia) ● Mechanical ventilation ● HX previous pneumothorax ● HX trauma ● ● Immunosuppression/ HIV ● Hospital admission ● Recent HX viral infection/ ‘the flu’ ● Smoker ● Alcohol excess ● Bronchiectesis (e.g. in CF) ● Bronchial obstruction (e.g. carcinoma) ● IVDU ● Dysphagia ● HX anxiety or depression ● HX panic attacks ● Interpersonal conflict or loss ● Injury ● Illness ● Use of stimulants (caffeine, decongestants, cocaine, sympathomimetics such as amphetamine, MDMA) ● DH SSRIs recently discontinued ● Obstructive pulmonary disorder ● IBS ● Frequent migraines● OCD ● Phobias ● HX MI ● Autoimmune disease ● Trauma ● Neoplasm ● Recent viral or bacterial infection ● HX TB/ rheumatic fever ● HIV positive ● Aortic valve disease ● Hypertrophic cardiomyopathy ● HX atheroma ● Smoker ● Hypertension ● Diabetes ● FH cardiovascular disease ● HX severe cough ● Trauma to chest ● Tietze syndrome ● Costochondritis ● Sternalis syndrome ● Fibromyalgia ● Sickle cell disease ● Hyperlipidaemia ● Recent infection with Chlamydia, Mycoplasma or viruses ● FH sickle cell disease ● African/ Indian/ Middle Eastern origin ● FH thrombosis ● Recent stasis/ immobility (in hospital/ long flight) ● Dehydration ● pregnancy ● combined oral contraceptive pill ● Obesity ● Varicose veins ● Recent surgery ● previous DVT/ embolism ● Trauma ● Infection ● Malignancy ● Congestive heart failure ● Recent MI ● Thrombophilia 
Bloods • FBC: May indicate iron-deficiency anaemia ● Cardiac enzyme tests: Troponin T and Troponin I raised. Should be checked at presentation, and subsequently at a later interval (often 6hrs (high sensitivity troponin test) or 12 hours ● Creatine kinase raised ● Serum alkaline phosphatase high ● Hypercalcaemia ● If no primary known, check tumour markers ● Leukocytosis (+/- eosinophilia) ● High ESR ● High CRP ● Rheumatologic screening ● High creatine kinase ● High cardiac troponins ● serum viral antibody titres No decisvie blood tests ● ABG: low O2 and high CO2 with respiratory acidosis ● Raised WCC ● Raised ESR >100mm/h ● Raised CRP ● Possible anaemia (if abscess) ● Blood cultures to identify organism ● All normal ● Leukocytosis if resulting from bacterial/ viral infection ● Often high cholesterol ● Cardiac markers (troponins) help differentiate from ACS ● All normal ● Hb low with high reticulocyte count ● High bilirubin ● Positive sickle solubility test ● ABG: O2 low, CO2 normal/low +/- metabolic acidosis ●D-dimer 
Imaging • Endoscopy: visual identification of inflammation • Barium swallow + water siphon test: may show presence of hiatus hernia or strictures • Radiolabelled technetium shows reflux.● CXR: cardiomegaly/ pulmonary oedema/ widened mediastinum ● CXR: may show lytic lesion ● CT: if radiography not conclusive ● Echocardiography to exclude other causes of heart failure ● Antimyosin scintigraphy identifies myocardial inflammation ● Gadolnium-enhanced MRI assesses extent of inflammation and cellular oedema ● CXR: left ventricular hypertrophy ● CXR: air in pleural space, trachea deviated away from pneumothorax if tension pneumothorax, lung collapse may be visible. (NB - if a tension pneumothorax, you shouldn't be doing a CXR, you should be decompressing immediately based on clinical signs!) ● CXR: consolidation 48h after onset of symptoms ● All normal ● None specific Angiography assesses the extent of angina ● All normal ● CXR: may take 2-3 days to show abnormalities ● CXR: normal/ pulmonary oedema signs (raised hemidiaphragm) +/- atelectasis ● VQ scan or CT depending on patients age and other factors 
Additional Investigations • 24-hr luminal pH + manometry confirms diagnosis by showing correlation between low oesophageal pH and symptoms. ● ECG: STEMI (peaked T wave and ST elevation. Definition: ST elevation of >2mm in at least 2 chest leads, or >1mm in at least 2 other leads)) / NSTEMI (look for other ECG changes, e.g. new LBBB) ● O2 sats: low ● Biopsy: diagnostic ● Staging CT if required ● Histology to identify microbial origin ● Echo ● None specific ● O2 sats ● All normal ● ECG: widespread saddle shaped ST elevation and PR interval depression. Later sign: T wave insertion and ST elevation in inferior and anterior leads ● ECG: normal / nil acute changes. If acute changes present, then ACS. ● Exercise tolerance test - ST depression (cardiac ischaemia) on exertion ● All normal ● Hb electrophoresis: Hb SS state ● ECG: Sinus tachycardia, T-wave inversion, new onset AF, right bundle branch block, right axis deviation ● Severe ECG changes: S waves in lead I, Q waves in lead III, T wave inversion in lead III 
Full Article GORDAcute Coronary SyndromesNot Available (Sorry!) - You could always write oneNot Available (Sorry!) - You could always write oneHypertrophic CardiomyopathyPneumothoraxPneumonia  and  Pneumonia in ChildrenFear Disorders  and  AnxietyPericarditisStable AnginaNot Available (Sorry!) - You could always write oneNot Available(Sorry!) - You could always write oneDVT and PE




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