Chest pain

Published on 10/02/2015 by admin

Filed under Emergency Medicine

Last modified 10/02/2015

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Chapter 3 Chest pain

Secondary survey (including history taking)

Having dealt with the potential life threatening cases you will be left with a group of patients for whom a more thorough clinical examination will be required before considering whether they can be either treated and left at home, or referred elsewhere.

Take a history of the presenting complaint, gather relevant information, and perform an examination (see Chapter 2).

For patients with chest pain, respiratory, cardiovascular, abdominal and musculoskeletal examinations are appropriate.

There is good evidence that history and examination cannot ‘rule out’ any specific diagnosis, especially acute myocardial infarction. Some types of pain are more commonly found in patients with ischaemia. However there is good evidence that history can help ‘risk stratify’ patients. In the context of acute chest pain, some other investigation will often be required.

The OPQRST of chest pain

Chest pain is often categorised into three main types (Table 3.1). It can be very difficult to place any particular patient into one of these categories, but there is evidence that the characteristics of pain can help in the diagnosis:

Somatic pain may arise from the chest wall (skin, ribs and intercostal muscles), pericardium (fibrous and parietal layer), and the parietal pleura. Pain from these structures is transmitted to the brain by the somatic nerve fibres that enable the brain to accurately locate the site of the problem. In the case of pleuritic chest pain, it will also be specifically related to movements of breathing.

Visceral pain in contrast originates from the deeper thoracic structures (heart, blood vessels and oesophagus) and is carried in the autonomic nerve fibres. These give a less precise location of the pain, and the pain is generally described as a discomfort, heaviness or ache. It is often referred to shoulders, arm or jaw.