Makindo Medical Notes

Related Subjects: |Assessing Chest Pain |Acute Coronary Syndrome (ACS) General |Aortic Dissection |Pulmonary Embolism |Acute Pericarditis |Diffuse Oesophageal Spasm |Gastro oesophageal reflux |Oesophageal Perforation Rupture |Pericardial Effusion Tamponade |Pneumothorax |Tension Pneumothorax |Shingles |Analgesia and Pain management

⚠️ In patients with significant chest pain, always consider the “big 3” killers: ❤️ Acute Coronary Syndrome (MI), 🫁 Pulmonary Embolism, and 🩻 Aortic Dissection. 👉 In hospitalised patients, PE is often the biggest concern. 🔑 Key acute tests: ECG, Troponin, D-dimer, and CTPA/Aortogram.

🚨 Acute Management of Chest Pain

Always assume chest pain = potentially life-threatening until proven otherwise. Apply ABCDE and treat reversible causes early. ⚡

1️⃣ Immediate Actions

• 🛏️ Place patient on bed with monitoring (ECG, SpO₂, BP, HR, RR, temp).
• 💉 Gain IV access (large bore) and take bloods (FBC, U&E, CRP, troponin, D-dimer, glucose, clotting).
• 💨 Oxygen only if hypoxic (SpO₂ <94%).
• 🩺 Brief history + exam focused on red flags (shock, collapse, severe SOB, unequal pulses).
• 📸 Immediate 12-lead ECG (ideally within 10 min of arrival).

📖 Introduction

Chest pain is one of the most common and high-risk acute presentations in medicine. It may reflect a benign musculoskeletal issue, but can also signal life-threatening conditions such as myocardial infarction, pulmonary embolism, or aortic dissection. A structured approach — focusing on history, risk factors, examination, and early investigations — is essential to avoid missed diagnoses.

📝 History

• ⏱ Onset & Timing: Sudden vs gradual, duration, constant vs intermittent.
• 📍 Character & Location: Crushing, sharp, pleuritic, retrosternal, localised.
• ↔️ Radiation: Arm, jaw, back, epigastrium.
• ⚡ Associated Symptoms: SOB, syncope, sweating, palpitations, nausea, haemoptysis.
• ⚠️ Red flags: Collapse, hypotension, neurological signs, haemodynamic instability.
• ❤️ Risk factors: Smoking, hypertension, diabetes, hyperlipidaemia, FHx IHD.
• 💊 Medications: Anticoagulants, recent steroids/NSAIDs (risk of PUD perforation).
• 🧠 Context: Exercise, stress, trauma, recent infection, immobilisation.

👩‍⚕️ Examination

• 🩺 General: ABCDE, vital signs (HR, BP both arms, O₂ sats, RR, temp).
• 👀 Inspection: Pallor, diaphoresis, distress, scars, trauma signs.
• 💓 Cardiac: JVP, heart sounds, murmurs, pulse character, pericardial rub.
• 🫁 Respiratory: Chest expansion, percussion, breath sounds, wheeze, crackles.
• 🦴 MSK: Localised tenderness, reproducible pain on palpation/movement.
• 🧠 Other: Neurological exam if collapse/weakness; abdominal exam if epigastric pain.

🩺 Acute Chest Pain – Key Differentials