Chest pain
Questionnaire/history:C/o chest pain (CP)? Onset? - Acute? Location? - Poorly localised, substernally, central or band-like across the anterior chest? - Localised, eg exclusively in right or left chest? Radiation? - Radiation to jaw, shoulders, arms, hands or back? Quality? - Dull, tightness, heaviness (as if someone has a heavy object sitting on the chest), constricting discomfort or crushing? - Sharp, stabbing or burning? Duration? - Momentary? - >15 minutes? - >1 hour? - >12 hours? Currently painfree? Last episode of pain? - Within 12 hours? Worse or better with exercise? Relieved by rest within about 5 minutes? Relieved by glyceryl trinitrate (GTN) within about 5 minutes? Worse on deep inspiration (pleuritic)? Worse by moving the arms or torso? Worse after eating a large meal? Associated symptoms? - Cough? - Breathlessness? - Nausea? - Vomiting? - Sweating? - Palpitations? - Dizziness? - Difficulty in swallowing? - Other? Associated symptoms in close proximity to the episodes of pain? Previous investigations? - ECG? - Chest X-ray? - Coronary angiogram? PMH? Current medication? Drug allergies? Examination: General appearance? - Pallor? - Sweating? BP in both arms? Pulse? Temperature? SpO2? JVP? Neck? Chest wall? RR? Chest? Heart sounds? Abdomen? Legs/ankles? - Swelling? - Tenderness? Skin? - Rash? - Bruising? Investigations: ECG? Diagnosis: For differential diagnosis see NICE CKS Management? Hospital admission as clinical features suggesting a serious cause: While waiting for ambulance: - Sat patient up - Offered oxygen as SpO2 < 94% (with face mask and flow rate to 5-10 L/min to achieve target SpO2 of 94-98% as not at risk of hypercapnic respiratory failure) - As chronic obstructive pulmonary disease with risk of hypercapnic respiratory failure, used 28% Venturi mask with flow rate at 4 L/min to achieve target SpO2 of 88-92% - As ACS suspected gave GTN and aspirin 300 mg - As acute pulmonary oedema suspected gave furosemide 40-80 mg slowly IV, metoclopramide 10 mg IV and GTN - As tension pneumothorax suspected and person's condition life threatening inserted large-bore cannula through 2nd ICS in the MCL on the side of the pneumothorax Urgent same-day assessment if: Suspected ACS + Pain-free with CP in the last 12 h + normal ECG + Pain-free with CP in the last 12-72 h + No complications Assessment within 2 weeks if: Suspected ACS + Pain-free with CP more than 72 h ago + No complications (Urgency decided on the basis of ECG, high-sensitivity blood troponin and advice from cardiologist) Suspected underlying malignancy Lung or lobar collapse or pleural effusion and admission not required Routine assessment if Suspected stable angina where diagnosis cannot be excluded in primary care (to consider aspirin 75 mg od) CP with unclear cause or clear diagnosis for CP, but symptoms persist despite management in primary care Reference(s): Hickam, D. A.: Chapter 9. Chest Pain or Discomfort, Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. 1990