1. Core Clinical Problems CHEST PAIN

2. Jane presents to her GP with chest pain What would you like to know?

3. Chest Pain Onset? Onset? Duration? Duration? Precipitating Factors? Precipitating Factors? Relieving factors? Relieving factors? Character? Character? Site? Site? Associations? Associations? Radiation? Radiation?

4. Chest Pain Onset? Onset? Duration? Duration? Precipitating Factors? Precipitating Factors? Relieving factors? Relieving factors? Character? Character? Site? Site? Associations? Associations? Radiation? Radiation? Intermittent?

5. Chest Pain Onset? Onset? Duration? Duration? Precipitating Factors? Precipitating Factors? Relieving factors? Relieving factors? Character? Character? Site? Site? Associations? Associations? Radiation? Radiation?

6. Chest Pain Onset? Onset? Duration? Duration? Precipitating Factors? Precipitating Factors? Relieving factors? Relieving factors? Character? Character? Site? Site? Associations? Associations? Radiation? Radiation? Emotion Exercise Food Weather Movement Cough Breathing Posture

7. Chest Pain Onset? Onset? Duration? Duration? Precipitating Factors? Precipitating Factors? Relieving factors? Relieving factors? Character? Character? Site? Site? Associations? Associations? Radiation? Radiation? Medicines Antianginal Antireflux Analgaesia Rest Posture

8. Chest Pain Onset? Onset? Duration? Duration? Precipitating Factors? Precipitating Factors? Relieving factors? Relieving factors? Character? Character? Site? Site? Associations? Associations? Radiation? Radiation? Sharp Heavy Tight Dull Gripping

9. Chest Pain Onset? Onset? Duration? Duration? Precipitating Factors? Precipitating Factors? Relieving factors? Relieving factors? Character? Character? Site? Site? Associations? Associations? Radiation? Radiation? Central Back Upper chest Side

10. Chest Pain Onset? Onset? Duration? Duration? Precipitating Factors? Precipitating Factors? Relieving factors? Relieving factors? Character? Character? Site? Site? Associations? Associations? Radiation? Radiation? Nausea Vomiting Sweating Presyncope Breathlessness Palpitations Ankle oedema

11. Chest Pain Onset? Onset? Duration? Duration? Precipitating Factors? Precipitating Factors? Relieving factors? Relieving factors? Character? Character? Site? Site? Associations? Associations? Radiation? Radiation? Jaw Arm(s) Back Epigastrium

12. Which system might be responsible for Jane’s chest pain?

13. Systems Cardiac Cardiac Respiratory Respiratory Gastrointestinal Gastrointestinal Musculoskeletal Musculoskeletal

14. Systems Cardiac Cardiac Respiratory Respiratory Gastrointestinal Gastrointestinal Musculoskeletal Musculoskeletal Central Heavy/Dull Radiates to jaw/arms/back Autonomic symptoms Exertional Relieved by GTN

15. Systems Cardiac Cardiac Respiratory Respiratory Gastrointestinal Gastrointestinal Musculoskeletal Musculoskeletal Worse on inspiration and coughing suggests pleural irritation. Dull discomfort may suggest soft tissue mass, pleural mass or local invasion.

16. Systems Cardiac Cardiac Respiratory Respiratory Gastrointestinal Gastrointestinal Musculoskeletal Musculoskeletal Indigestion Heartburn Spasms difficult to differentiate from cardiac Relation to posture and food

17. Systems Cardiac Cardiac Respiratory Respiratory Gastrointestinal Gastrointestinal Musculoskeletal Musculoskeletal History of trauma Worse on breathing, movement and touch

18. 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.

19. What type of pain does she have? 1. Cardiac 2. Pericardial 3. Musculoskeletal 4. Pleuritic 5. Oesophageal

20. 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

21. What diagnosis should you consider? 1. Myocardial Infarction 2. Angina 3. Pneumonia 4. Costochondritis 5. Pulmonary Embolism

22. 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

23. What diagnosis is most likely? 1. Musculoskeletal 2. Pleurisy 3. Acute Coronary Syndrome 4. GORD 5. Pneumothorax

24. He tells you that his pain is central, sharp in character and worsens when he lies down flat This is his ECG:

26. The diagnosis is... 1. Pericarditis 2. Pneumonia 3. Atrial fibrillation 4. Pulmonary Embolism 5. Wolf Parkinson White type B

27. 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.

28. What could be causing his pain? 1. Angina 2. Myocardial Infarction 3. GORD 4. Oesophageal spasms 5. Pericarditis

30. What would you like to do next? 1. Trial of proton pump inhibitor 2. Oesophageal manometry 3. Gastroscopy 4. Exercise Tolerance Test (ETT) (Treadmill) 5. Coronary Angiogram

31. 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

32. Examination reveals reduced breath sounds, percussion note and vocal resonance over the left lung

33. Which of the following diagnosis is likely? 1. Benign asbestos disease 2. Mesothelioma 3. Lymphoma 4. TB 5. Pneumonia

34. End