Musculoskeletal (chest wall) incl. costochondritis
Serious disorders not to be missed
Fractured rib (e.g. cough fracture)
Precordial catch (‘stitch’ in side)
Bornholm disease (pleurodynia)
cocaine inhalation (can ↑ ischaemia)
Is the patient trying to tell me something?
Consider functional causes, especially anxiety with hyperventilation, opioid dependency.
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).
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.
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.