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++

Probability diagnosis

++

Musculoskeletal (chest wall) incl. costochondritis

++

Psychogenic

++

Angina

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Serious disorders not to be missed

++

Cardiovascular:

++

  • myocardial infarction/unstable angina

  • aortic dissection

  • pulmonary embolism/infarction

++

Neoplasia/cancer:

++

  • lung cancer

  • tumours of spinal cord and meninges

++

Infection:

++

  • pneumonia/pleuritis (pleurisy)

  • mediastinitis

  • pericarditis

  • myocarditis

++

Pneumothorax

++

Pitfalls (often missed)

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Mitral valve prolapse

++

Oesophageal spasm

++

Gastro-oesophageal reflux

++

Biliary colic

++

Peptic ulcer

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Herpes zoster

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Fractured rib (e.g. cough fracture)

++

Spinal dysfunction

++

Precordial catch (‘stitch’ in side)

++

Rarities:

++

  • pancreatitis

  • Bornholm disease (pleurodynia)

  • cocaine inhalation (can ↑ ischaemia)

  • hypertrophic cardiomyopathy

++

Masquerades checklist

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Depression (possible)

++

Anaemia (indirect)

++

Spinal dysfunction

++

Is the patient trying to tell me something?

++

Consider functional causes, especially anxiety with hyperventilation, opioid dependency.

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Key history

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This needs to be meticulous because of the life-threatening causes. Analyse the pain into its usual characteristics with the SOCRATES system.

++

   Note family history drug history, psychosocial history and past history, especially if immunocompromised (e.g. diabetes or metabolic syndrome).

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Key examination

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  • General appearance

  • Vital signs

  • Peripheral circulation

  • Careful examination of cardiovascular and respiratory systems

  • Upper abdominal palpation

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Key investigations

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  • Base tests available to the GP are ECG, cardiac enzymes and CXR and in most instances help confirm the diagnosis.

  • Otherwise specialist investigations including imaging are confined to hospitals and cardiology centres.

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Diagnostic tips

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  • Consider chest pain as due to a coronary syndrome until proved otherwise.

  • The history remains the most important clinical factor in the diagnosis of ischaemic heart disease and other conditions.

  • With angina a vital clue is the reproducibility of the symptom.

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