Core Clinical Problems CHEST PAIN. Jane presents to her GP with chest pain What would you like to know?

Core Clinical Core Clinical ProblemsProblems

CHEST PAINCHEST PAIN

Jane presents to Jane presents to her GP with her GP with chest painchest painWhat would you like to know?What would you like to know?

Chest PainChest Pain

Onset?Onset? Duration?Duration? Precipitating Precipitating

Factors?Factors? Relieving factors?Relieving factors? Character?Character? Site?Site? Associations?Associations? Radiation?Radiation?




Intermittent?Intermittent?







EmotionEmotion ExerciseExercise FoodFood WeatherWeather MovementMovement CoughCough BreathingBreathing PosturePosture




MedicinesMedicines AntianginalAntianginal AntirefluxAntireflux AnalgaesiaAnalgaesia

RestRest PosturePosture




SharpSharp HeavyHeavy TightTight DullDull GrippingGripping




CentralCentral BackBack Upper chestUpper chest SideSide




NauseaNausea VomitingVomiting SweatingSweating PresyncopePresyncope BreathlessnessBreathlessness PalpitationsPalpitations Ankle oedemaAnkle oedema



Factors?Factors? Relieving factors?Relieving factors? Character?Character? Site?Site? Associations?Associations? Radiation? Radiation?

JawJaw Arm(s)Arm(s) BackBack EpigastriumEpigastrium

Which system Which system might be might be

responsible for responsible for Jane’s chest pain?Jane’s chest pain?

SystemsSystems

CardiacCardiac RespiratoryRespiratory GastrointestinalGastrointestinal Musculoskeletal Musculoskeletal

SystemsSystems


CentralCentral Heavy/DullHeavy/Dull Radiates to Radiates to

jaw/arms/backjaw/arms/back Autonomic Autonomic

symptomssymptoms ExertionalExertional Relieved by GTNRelieved by GTN

SystemsSystems


Worse on Worse on inspiration and inspiration and coughing suggests coughing suggests pleural irritation.pleural irritation.

Dull discomfort Dull discomfort may suggest soft may suggest soft tissue mass, tissue mass, pleural mass or pleural mass or local invasion.local invasion.

SystemsSystems


IndigestionIndigestion HeartburnHeartburn Spasms difficult to Spasms difficult to

differentiate from differentiate from cardiaccardiac

Relation to posture Relation to posture and foodand food

SystemsSystems


History of traumaHistory of trauma Worse on Worse on

breathing, breathing, movement and movement and touchtouch

Jane is 31 and suffers from Jane is 31 and suffers from systemic lupus erythematosis systemic lupus erythematosis (SLE). She presents with left (SLE). She presents with left

sided chest pain which is worse sided chest pain which is worse on inspiration and coughing. on inspiration and coughing. Movement or touch does not Movement or touch does not

worsen the pain.worsen the pain.

What type of pain does What type of pain does she have?she have?

1 2 3 4 5

0% 0% 0%0%0%

1.1. CardiacCardiac

2.2. PericardialPericardial

3.3. MusculoskeletaMusculoskeletall

4.4. PleuriticPleuritic

5.5. OesophagealOesophageal

She tells you that the pain came She tells you that the pain came on suddenly earlier this morning on suddenly earlier this morning

and that she felt light headed and that she felt light headed and breathless with it. and breathless with it.

There was no sputum or feverThere was no sputum or fever

What diagnosis should What diagnosis should you consider?you consider?

1 2 3 4 5

0% 0% 0%0%0%

1.1. Myocardial Myocardial InfarctionInfarction

2.2. AnginaAngina

3.3. PneumoniaPneumonia

4.4. CostochondritisCostochondritis

5.5. Pulmonary Pulmonary EmbolismEmbolism

John is 26 he presents to you John is 26 he presents to you with central chest pain. He with central chest pain. He has never smoked, has no has never smoked, has no family history of IHD and family history of IHD and suffers from no medical suffers from no medical

illness.illness.He recalls helping a friend He recalls helping a friend

move furniture two days agomove furniture two days ago

What diagnosis is most What diagnosis is most likely?likely?

1 2 3 4 5

0% 0% 0%0%0%

1.1. MusculoskeletaMusculoskeletal l

2.2. PleurisyPleurisy

3.3. Acute Coronary Acute Coronary SyndromeSyndrome

4.4. GORDGORD

5.5. PneumothoraxPneumothorax

He tells you that his pain is He tells you that his pain is central, sharp in character central, sharp in character and worsens when he lies and worsens when he lies

down flatdown flatThis is his ECG:This is his ECG:

The diagnosis is...The diagnosis is...

1 2 3 4 5

0% 0% 0%0%0%

1.1. PericarditisPericarditis


3.3. Atrial Atrial fibrillationfibrillation

4.4. Pulmonary Pulmonary EmbolismEmbolism

5.5. Wolf Parkinson Wolf Parkinson White type BWhite type B

John is 58. He is a smoker John is 58. He is a smoker who presents to his GP with who presents to his GP with

central chest pain. He is central chest pain. He is overweight and has suffered overweight and has suffered

from heartburn and from heartburn and indigestion for a number of indigestion for a number of

years. His pain can be years. His pain can be brought on by stress, heavy brought on by stress, heavy

meals and exercise. meals and exercise.

What could be causing What could be causing his pain?his pain?

1 2 3 4 5

0% 0% 0%0%0%

1.1. AnginaAngina

2.2. Myocardial Myocardial InfarctionInfarction

3.3. GORDGORD

4.4. Oesophageal Oesophageal spasmsspasms

5.5. PericarditisPericarditis

What would you like to What would you like to do next?do next?

1 2 3 4 5

0% 0% 0%0%0%

1.1. Trial of proton pump Trial of proton pump inhibitorinhibitor

2.2. Oesophageal Oesophageal manometrymanometry

3.3. GastroscopyGastroscopy

4.4. Exercise Tolerance Exercise Tolerance Test (ETT) Test (ETT) (Treadmill)(Treadmill)

5.5. Coronary AngiogramCoronary Angiogram

Michael is 61. He is a life long Michael is 61. He is a life long smoker and had worked in the smoker and had worked in the

shipyards in the past. He shipyards in the past. He presents with mild chest ache presents with mild chest ache that has occurred insidiously that has occurred insidiously

associated with breathlessness associated with breathlessness and weight lossand weight loss

Examination reveals reduced Examination reveals reduced breath sounds, percussion breath sounds, percussion note and vocal resonance note and vocal resonance

over the left lungover the left lung

Which of the following Which of the following diagnosis is likely?diagnosis is likely?

1 2 3 4 5

0% 0% 0%0%0%

1.1. Benign Benign asbestos asbestos diseasedisease

2.2. MesotheliomaMesothelioma

3.3. LymphomaLymphoma

4.4. TBTB


EndEnd

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Core Clinical Problems CHEST PAIN. Jane presents to her GP with chest pain What would you like to know?