Chest pain

Chest pain

1. Differential diagnosis

   • Aged over 60
     • ACS & Stable angina
     • PE
     • Pleurisy secondary to infection
     • Oesophagitis secondary to GORD/hiatus hernia
     • Anxiety
     • Px
     • Boerhaave's perforation of OPS
     • Cholcystitis/pancreatitis
     • Aortic aneurysm
   • Younger pt
     • ACS & Stable angina
     • Myopericarditis( usually post-infarction)
     • Aortic dissection
     • Aortic aneurysm
   • Younger female on COC pill
     • PE
     • Px( esp if tall and thin)
     • Cocaine induced spasm( rare)

2. Immediate assessment

   • Assess ABC
   • Reassure the pt
   • Allow pt to sit/lie in whatever position is most comfortable
   • Obtain a 12 lead ECG immediately(within 5-10 mins of arrival)
   • High conc of oxygen by mask if oxygen sat is < 94% on air
   • Connect pt to monitoring devices( ECG,BP, sats)
   • Venous access and blds for routine tests. Samples for cardiac markers( usually 12 h after the onset of pain for troponins)
   • Request an urgent CXR/ consider need for early analgesia

3. Hx

   • SOCRATES for pain

4. Physical Exam

   • Pallor, sweating/cyanosis
   • Abnormal pulse/BP
   • Raised JVP/oedema
   • Added heart sounds
   • Changed resp rate and pattern
   • Low sats
   • Reduced air entry and abnormal breath sounds
   • Abdo tenderness-esp epigastric and renal pain( which may mimic chest pain) and hepatic discomfort( CCF)

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