Chest pain questions:

Where –> system involved

What –> pathology

How –> functional limitation

Why –> aetiology

  1. Patient’s age
  2. SOCRATES – site, onset, character, radiation, associated symptoms, time course, exacerbating/relieving factors, and severity.

Character:

  • crushing or pressure –> cardiac
  • tearing pain through to back –> dissection
  • sharp, stabbing –> pulmonary
  • burning, ‘indigestion’ –> GI

…but be careful with character, because there is lots of overlap

Onset:

  • exertional –> IHD
  • progressive onset at rest –> MI
  • sudden onset –> PE, dissection or pneumothorax
  • after meals –> GI

Location: superficial and localised –> somatic

Radiation:

  • to the back –> dissection, pancreatitis, posterior ulcer (MI possible)
  • arms/neck/jaw –> IHD
  • located primarily in the back, especially interscapular –> dissection

Duration:

  • maximal at onset –> aortic dissection
  • lasts only for a few minutes –> IHD

Exacerbating/relieving factors:

  • worsens with exertion, relieved with rest –> IHD
  • related to meals –> GI
  • worsens with respiration –> pulmonary, pericardial and musculoskeletal

Associated Sx:

  • haemoptysis –> PE
  • dyspnoea –> CV or pulmonary
  • nausea and vomiting –> CV or GI

Previous episodes; ask about testing (ECG, echo or angiography)

  1. Specific questions –
  • HoPC:

· Associated with dyspnoea? Worse when lying down (orthopnoea)? How many pillows do you sleep with? Do you wake up at night, gasping for breath (paroxysmal nocturnal dyspnoea)?

· Ankle swelling (symmetrical and worse in the evening, but improves overnight)?

· Palpitations? Are they of sudden or gradual onset (cardiac arrhythmias are instantaneous, sinus tachycardia is slow onset)? Are they associated with pain, dyspnoea or faintness? Ask patient to tap out beat.

· Syncopal episodes (episodes of fainting)? Do they occur when standing up suddenly? Ask about anti-anginal and antihypertensive drugs that may cause postural hypotension. Do they occur with exertion?

· Intermittent claudication?

· Fatigue?

· Anorexia?

· Weight loss?

· Fever?

· PMH:

· Smoker?

· Heart attack? Other heart problems? (IHD)

· Hypertensive? (IHD)

· Lipid profile? (IHD)

· Diabetic? (IHD)

· Trauma? (pancreas)

· Gallstones? (choledocholithiasis)

· Asthma? (eosinophilic oesophagitis)

· Reflux? (GI)

· Ulcers? (GI)

· Pancreatitis? (GI)

· Recent long-distance travel or other long period of immobilization?

· Previous surgery? To abdomen? (cholecystectomy, pancreatectomy)

· Previous gastroscopy/colonoscopy?

· Medication:

· NSAIDs? Aspirin? Alcohol? à all potential causes of gastritis

· Alcohol consumption? (pancreas)

· Any recent changes to medications?

· FH:

· Cancer?

· Cardiac disease?

  1. Questions to ask all the time:

· Smoker?

· Appetite?

· Weight loss?

· Any recent changes to medications?

· Allergies?

· Diabetic?

Differential Diagnoses:

CV aetiologies:

  • AMI
  • Aortic dissection
  • Angina
  • Pericarditis

Pulmonary aetiologies

  • PE
  • Pneumonia
  • Pneomothorax
  • COPD/Asthma exacerbation
  • Lung cancer

Gastrointestinal aetiologies

  • GORD
  • Gastritis – pain not associated with dyspnoea or exertion, and not very severe
  • Peptic ulcer disease – chronic pain assoc/w food; lasts hours-days
  • Oesophageal spasm/eosinophilic oesophagitis/achalasia
  • Pancreatitis
  • Cholecystitis/choledocholithiasis
  • Acute Hepatitis

Musculoskeletal aetiologies

3 major life-threatening possibilities:

*AMI*

*PE*

*Aortic dissection*