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Probability diagnosis

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Musculoskeletal (chest wall) incl. costochondritis

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Psychogenic

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Angina

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Serious disorders not to be missed

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Cardiovascular:

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  • myocardial infarction/unstable angina

  • aortic dissection

  • pulmonary embolism/infarction

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Neoplasia/cancer:

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  • lung cancer

  • tumours of spinal cord and meninges

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Infection:

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  • pneumonia/pleuritis (pleurisy)

  • mediastinitis

  • pericarditis

  • myocarditis

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Pneumothorax

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Pitfalls (often missed)

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Mitral valve prolapse

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Oesophageal spasm

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Gastro-oesophageal reflux

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Biliary colic

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Peptic ulcer

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Herpes zoster

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Fractured rib (e.g. cough fracture)

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Spinal dysfunction

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Precordial catch (‘stitch’ in side)

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Rarities:

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  • pancreatitis

  • Bornholm disease (pleurodynia)

  • cocaine inhalation (can ↑ ischaemia)

  • hypertrophic cardiomyopathy

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Masquerades checklist

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Depression (possible)

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Anaemia (indirect)

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Spinal dysfunction

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Is the patient trying to tell me something?

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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.

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   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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