Introduction
- Assuming the patient is not critically unwell or has ECG findings of a STEMI, then a more systematic history should be taken
- Chest Pain can arise from several organs: heart, major thoracic vessels. lungs, pleura, chest wall, upper GI tract and the hepato-biliary system
- Don’t forget the great mimicker, herpes zoster (shingles)
- It is useful to take a review of systems and PMHx related to the respiratory and digestive system.
| History | Exam | Confirmatory Testng | |
| Aortic dissection | Abrupt onset of sudden tearing chest pain radiating to interscapular region
Hypertensive |
Unequal BP in arms (subclavian extension)
Stroke like symptoms (carotid extension) Bilateral neurological symptoms (spinal artery extension) Lower limb ischaemia (descending aorta extension) Aortic regurgitation (aortic valve extension) Shock (pericardial extension) |
CT angiogram
(or Trans-oesophageal echocardiogram) |
| Pulmonary embolism | Unexplained hypoxia i.e. chest clear and normal CXR
Wells > 0 or PERC positive |
Tachycardia
Hypoxia (may be normal) |
CTPA or V/Q scan |
| Gallstones | Previous episodes related to food | LFTs Biliary Ultrasound |
|
| GOR | Previous episodes related to food | ||
| Gastric volvulus | Prominent vomiting
Abrupt onset of pain |
AXR/CXR CT abdomen |
|
| Boehaaves | Abrupt onset of pain | Hamman’s crunch | |
| Oesophageal rupture | Abrupt onset of pain | AXR/CXR CT abdomen |
|
| Herpes Zoster | Gradual onset of unexplained unilateral pain or dysthesia | Unilateral rash in truncal dermantome | |
| Pneumonia | Fever
Productive Cough
|
Focal chest findings | CXR |
| Pancreatitis | Prominent vomiting | Epigastric tenderness | LFTs Lipase Upper abdominal ultrasound CT |