Core Clinical Problems
CHEST PAIN
Jane presents to her GP
with chest pain
What would you like to know?
Chest Pain
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Onset?
Duration?
Precipitating Factors?
Relieving factors?
Character?
Site?
Associations?
Radiation?
Chest Pain
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Onset?
Duration?
Precipitating Factors?
Relieving factors?
Character?
Site?
Associations?
Radiation?
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Intermittent?
Chest Pain
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Onset?
Duration?
Precipitating Factors?
Relieving factors?
Character?
Site?
Associations?
Radiation?
Chest Pain
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Onset?
Duration?
Precipitating Factors?
Relieving factors?
Character?
Site?
Associations?
Radiation?
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Emotion
Exercise
Food
Weather
Movement
Cough
Breathing
Posture
Chest Pain
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Onset?
Duration?
Precipitating Factors?
Relieving factors?
Character?
Site?
Associations?
Radiation?
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Medicines
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Antianginal
Antireflux
Analgaesia
Rest
Posture
Chest Pain
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Onset?
Duration?
Precipitating Factors?
Relieving factors?
Character?
Site?
Associations?
Radiation?
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Sharp
Heavy
Tight
Dull
Gripping
Chest Pain
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Onset?
Duration?
Precipitating Factors?
Relieving factors?
Character?
Site?
Associations?
Radiation?
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Central
Back
Upper chest
Side
Chest Pain
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Onset?
Duration?
Precipitating Factors?
Relieving factors?
Character?
Site?
Associations?
Radiation?
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Nausea
Vomiting
Sweating
Presyncope
Breathlessness
Palpitations
Ankle oedema
Chest Pain
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Onset?
Duration?
Precipitating Factors?
Relieving factors?
Character?
Site?
Associations?
Radiation?
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Jaw
Arm(s)
Back
Epigastrium
Which system might be
responsible for Jane’s
chest pain?
Systems
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Cardiac
Respiratory
Gastrointestinal
Musculoskeletal
Systems
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Cardiac
Respiratory
Gastrointestinal
Musculoskeletal
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Central
Heavy/Dull
Radiates to
jaw/arms/back
Autonomic symptoms
Exertional
Relieved by GTN
Systems
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Cardiac
Respiratory
Gastrointestinal
Musculoskeletal
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Worse on inspiration and
coughing suggests
pleural irritation.
Dull discomfort may
suggest soft tissue mass,
pleural mass or local
invasion.
Systems
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Cardiac
Respiratory
Gastrointestinal
Musculoskeletal
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Indigestion
Heartburn
Spasms difficult to
differentiate from cardiac
Relation to posture and
food
Systems
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Cardiac
Respiratory
Gastrointestinal
Musculoskeletal
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History of trauma
Worse on breathing,
movement and touch
Jane is 31 and suffers from systemic lupus
erythematosis (SLE). She presents with left
sided chest pain which is worse on
inspiration and coughing. Movement or
touch does not worsen the pain.
What type of pain does she have?
1.
2.
3.
4.
5.
Cardiac
Pericardial
Musculoskeletal
Pleuritic
Oesophageal
0%
1
0%
2
0%
0%
3
4
0%
5
She tells you that the pain came on
suddenly earlier this morning and that she
felt light headed and breathless with it.
There was no sputum or fever
What diagnosis should you
consider?
1.
2.
3.
4.
5.
Myocardial
Infarction
Angina
Pneumonia
Costochondritis
Pulmonary
Embolism
0%
1
0%
2
0%
0%
3
4
0%
5
John is 26 he presents to you with
central chest pain. He has never
smoked, has no family history of IHD
and suffers from no medical illness.
He recalls helping a friend move
furniture two days ago
What diagnosis is most likely?
1.
2.
3.
4.
5.
Musculoskeletal
Pleurisy
Acute Coronary
Syndrome
GORD
Pneumothorax
0%
1
0%
2
0%
0%
3
4
0%
5
He tells you that his pain is central,
sharp in character and worsens when
he lies down flat
This is his ECG:
The diagnosis is...
1.
2.
3.
4.
5.
Pericarditis
Pneumonia
Atrial fibrillation
Pulmonary
Embolism
Wolf Parkinson
White type B
0%
1
0%
2
0%
0%
3
4
0%
5
John is 58. He is a smoker who
presents to his GP with central chest
pain. He is overweight and has
suffered from heartburn and
indigestion for a number of years. His
pain can be brought on by stress,
heavy meals and exercise.
What could be causing his pain?
1.
2.
3.
4.
5.
Angina
Myocardial
Infarction
GORD
Oesophageal spasms
Pericarditis
0%
1
0%
2
0%
0%
3
4
0%
5
What would you like to do next?
1.
2.
3.
4.
5.
Trial of proton pump
inhibitor
Oesophageal manometry
Gastroscopy
Exercise Tolerance Test
(ETT) (Treadmill)
Coronary Angiogram
0%
1
0%
2
0%
0%
3
4
0%
5
Michael is 61. He is a life long smoker and
had worked in the shipyards in the past. He
presents with mild chest ache that has
occurred insidiously associated with
breathlessness and weight loss
Examination reveals reduced breath
sounds, percussion note and vocal
resonance over the left lung
Which of the following diagnosis
is likely?
1.
2.
3.
4.
5.
Benign asbestos
disease
Mesothelioma
Lymphoma
TB
Pneumonia
0%
1
0%
2
0%
0%
3
4
0%
5
End