HOW TO APPROACH CHEST PAIN ?

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 Differential diagnosis of chest pain
Chest pain

Cardiac Non cardiac

Ischemic Non ischemic GI Pulmonary Musculoskeletal Psychogenic

Type Causes Important feature

Ischemic Angina -Sub sternal

-Heaviness ,tightness, pressure like
-Almost never sharp and can not be pointed
-Doesn’t change with respiration or position
-May radiate to the left shoulder ,left arm left jaw
-Gradual

Infarction MI -Central chest pain

-Severe pain
-Subacute onset (minutes)
-Onset at rest
-No relief with nitrates
-Associated symptoms (nausea, vomiting AND
Sweating )
Pleuritic pain Pericarditis -Sharp, stabbing
Pleuritis -Change with position and respiration
Pneumothorax -Sudden
Pneumonia -Might come with fever
Pulmonary embolus
Musculoskeletal Costochondritis -Positional
related -Often worse at rest
Sternoclavicular arthritis -Localised
-Chest wall tenderness
Herpes zoster

Vascular pain Aortic dissection -Very sudden onset, radiates to the back

Airway pain Tracheitis -Pain in throat, breathing painful

Central bronchial
carcinoma
Inhaled foreign body
Question Think about

SOCRATES
Site
-Diffuse, poorly loclaized or retrosternal Myocardial ischemia or PE

Musculoskeletal pain
-Localized over skin and superfaicial strictures, reproduced by Costochondritis, chest wall syndrome
palpation
Noncardiac pain (musculoskeletal, psychogenic,
-Localized in region of the left nipple gaseous distention of the stomach)

Onset: how long does last?

Noncardiac
-very Brief (<15 seconds) Musculoskeletal pain
Hiatal hernia
Psychogenic pain
Angina pectoris
-brief (2-20 min) Esophageal disease
Musculoskeletal pain
Psychogenic pain
UA/MI
Acute GI pathology
-Prolonged (>20 minutes to houres) Pulmonary disorders
Pericarditis
Aortic dissection
Musculoskeletal disease
Herpes zpster
Psychogenic pain
Character: how does it feel like?

-pressure, squeezing, burning, or strangling Myocardial ischemia

-sever tearing or ripping Aortic dissection

Pericarditis, pleuritis
-sharp or stabbing PE, pneumothorax
Musculoskeletal pain
Psychogenic pain

-dull, persistent ache lasting from hours to days localized to Psychogenic pain
cardiac apex
Reliving factors ?

Angina pectoris
-Rest or sublingual nitroglycerine Esophageal spasm (takes longer time)
-sitting up and leaning forward Pericarditis
Pancreatitis
-antacids or food Esophagitis, peptic ulcer
-holding the breath at deep expiration Pleuritis
 Personal data
Chef complain (chest pain)
Question: SOCRATES Think about

Associated symptoms ?
Acute myocardial ischemia or MI
-Vomiting and nausea Acute GI pathology
Acute myocardial ischemia or MI
-Diaphoresis PE
Aortic dissection
-Cough Pleuritis
PE

-Dyspnea Acute myocardial ischemia or MI

PE
Pneumothorax
Pneumonia
Acute myocardial ischemia or MI
-Hypotension and syncope Massive PE
Aortic stenosis
Arrhythmia
-Hemoptysis PE, pneumonia
Pneumonia
-Fever Pleuritis
Pericarditis

-Acid reflex into the mouth GERD

-Difficulty in swallowing? esophageal spasm

Time: Abrupt or gradual, continuous or intermittent (if

intermittent ask about frequency)
Exacerbating factors:

-Excretion Angina pectoris

-Emotional stress or freight Angina pectoris
Psychogenic pain
-Eating and meals Esophageal pain
Peptic ulcer
Angina pectoris
-lying down after meals Esophageal reflux
-Bending or moving the neck Cervical/upper thoracic spine disease

-Respiration or cough PE
Pneumothorax
Pericarditis, pleuritic
-Change in body position Pericarditis
Musculoskeletal pain
Pancreatitis
Severity: Scored out of 10 or how does it affect daily work?

Past medical & surgical history

Family history & social & systemic review

 Risk Factors
➔ Smoker
➔ Any heart trouble before ? What sort? What treatment
➔ Cholesterol level ? did you have?
➔ Are you diabetic? How well controlled is your diabetes?
➔ Have you had high blood pressure ?
➔ Have there been problems in your family with heart
disease?

Narrowing the DDx

Acute or ongoing
chest pain

Sharp pleuritic pain

Severe tearing or Musculoskeletal features
Typical anginal pain Diffuse Very brief sharp, stabbing pain
ripping pain
retrosternal pressure, Localized (< 3 cm) dull ache
Radiation to back
Radiation to left or right arm Radiation to shoulders Superficial chest wall location,
Diaphoresis
Associated symptoms Radiation to back worse with palpation
Neurologic symptoms
(eg, dyspnea, nausea/vomiting, Relief: Leaning forward Positional or pleuritic pain
History of
diaphoresis, syncope) Aggravated by : cough Worse with neck/arm motion
hypertension or
Marfan syndrome swallowing,
Cocaine use

Myocardial Musculoskeletal pain

Pericarditis
ischemia or infarction Psychogenic pain
Also consider: Aortic dissection
Pulmonary embolism
Esophageal or Gl pain
Psychogenic pain
Dyspnea Gastrointestinal features
(especially sudden onset) Epigastric Lower
Diaphoresis With chest pain
or without Pain with eating or lying down
hemoptysis or syncope after meals
Waterbrash or nausea
Atypical angina Positional changes
Relief with antacids

Pulmonary embolism
Assess probability Pneumothorax
of coronary artery Esophageal or
Pneumonia
Moderate/ disease other GI cause
Pleuritis
high
Low (Consider mitral prolapse)

Typical angina :Meets all three of the following

Characteristic retrosternal chest discomfort—typical quality and duration
Provoked by exertion or emotion, Relieved by rest or GTN (glyceryl trinitrate) or both
Atypical angina: Meets two of the above characteristics

Done by :Abdulrahman Al Mizel & Mohammad Alotaibi

Revised by : Nada Alamri

Feel free to contact us on: OSCE434@gmail.com