1. Chest Pain
Mudher Al-khairalla

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

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

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

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

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

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

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

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

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

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

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

13. Systems
Cardiac
Respiratory
Gastrointestinal
Musculoskeletal

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

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

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

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

18. Jane is 31 and suffers from systemic lupus erythematosis (SLE)
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?
Cardiac
Pericardial
Musculoskeletal
Pleuritic
Oesophageal

20. What type of pain does she have?
Cardiac
Pericardial
Musculoskeletal
Pleuritic
Oesophageal

21. 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

22. What diagnosis should you consider?
Myocardial Infarction
Angina
Pneumonia
Costochondritis
Pulmonary Embolism

23. What diagnosis should you consider?
Myocardial Infarction
Angina
Pneumonia
Costochondritis
Pulmonary Embolism

24. John is 26 he presents to you with central chest pain
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

25. What diagnosis is most likely?
Musculoskeletal
Pleurisy
Acute Coronary Syndrome
GORD
Pneumothorax

26. What diagnosis is most likely?
Musculoskeletal
Pleurisy
Acute Coronary Syndrome
GORD
Pneumothorax

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

28. This is his ECG

30. The diagnosis is… Pericarditis Pneumonia Atrial fibrillation
Pulmonary Embolism
Wolf Parkinson White type B

31. The diagnosis is… Pericarditis Pneumonia Atrial fibrillation
Pulmonary Embolism
Wolf Parkinson White type B

32. 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.

33. What could be causing his pain?
Angina
Myocardial Infarction
GORD
Oesophageal spasms
Pericarditis

34. What could be causing his pain?
Angina
Myocardial Infarction
GORD
Oesophageal spasms
Pericarditis

35. His 12 lead ECG is normal

36. What would you like to do next?
Trial of proton pump inhibitor
Oesophageal manometry
Gastroscopy
Exercise Tolerance Test (ETT) (Treadmill)
Coronary Angiogram

37. What would you like to do next?
Trial of proton pump inhibitor
Oesophageal manometry
Gastroscopy
Exercise Tolerance Test (ETT) (Treadmill)
Coronary Angiogram

38. 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

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

40. Which of the following diagnosis is likely?
Benign asbestos disease
Mesothelioma
Lymphoma TB
Pneumonia

41. Which of the following diagnosis is likely?
Benign asbestos disease
Mesothelioma
Lymphoma TB
Pneumonia

42. End