Medical School Lesson Plan – Chest Pain

Picture the scene…

It’s your second day as a doctor when you are called to see one of your patients who has suddenly developed chest pain…

Learning Objective

To learn about the management of the patient with chest pain.

Read this blog post from RCEM Learning. Note that often emergency care our approach is “rule out the worst case scenario”, rather than “make a diagnosis”. In patients with chest pain those diagnoses we want to rule out are: ACS/myocardial infarction; aortic dissection; Pulmonary Embolus and Pneumothorax​1​.

Listen to this St Emlyn’s podcast with Simon and Iain, which will reenforce the learning from the RCEM article.

This part of the teaching session should be lead by an experienced clinician. The cases provided are merely examples and if possible the learners should be encouraged to discuss patients they have seen in their clinical practice.

A 60 year old man presents to ED triage with sudden onset chest pain going through to his back. He describes it as “tearing” in nature. He has no past medical history, is not on any medication apart from antihypertensives (which he doesn’t like taking!) and his examination is normal (apart from a blood pressure of 180/100 – which he tells you always happens when he is in hospital.

This patient should be moved to the Resuscitation Room. Although he seems relatively well, he pain is very concerning for aortic dissection and he needs regular monitoring and close observation.

Firstly inform a senior! This patient is potentially very unwell and may have a life threatening diagnosis.

Your senior will give you advice about what to do next, but it will likely involve an echocardiogram (especially if the patient becomes hypotensive) and/or a CT aortogram. The echo can show a dissection falp and cruically look for a pericardial effusion (+/- tamponade). Although aortic dissection is a rare diagnosis it isn’t one we can miss as it can be life threatening. If the diagnosis is even contemplated you need to do investigations that will rule it out as much as possible.

You are on the surgical ward round when you are asked to assess a 35 year old post op patients. She feels short of breath on exertion and her oxygen saturations are 95% on air.

The key diagnosis to rule out here is pulmonary embolism. Although rare in the under 40s there are not many other serious reasons for chest pain in this patient. Her key risk factors for PE is just having had surgery, but you should ask about others too: including family history, history of travel; immobilisation (due to hospitalization, recovery from injury, bedrest, or paralysis); pregnancy; certain medications or a history of thrombophilia. Clinical signs in additon to (pleuritic) chest pain include haemoptysis and shortness of breath.

It would be reasonable to start with some form of validated risk assessment tool like the PERC score or the Well’s score. If indicated a d-dimer could be used in addition – it is a good test to say a patient doesn’t have a PE (sensitive), but if positive does not necesssarily mean the patient does have one (not specific). D-dimer is often hard to interpret in post operative patients as it wqill ten be positive.

A chest xray may be performed, but usually this will be to look for other causes of chest pain, such as a pneumothorax.

If suspicion remains after these tests have been completed then a CT Pulmonary Angiogram is the test of choice (CTPA).

In this session we have learned about the clinical assessment of the patient with chest pain

Consider these questions based on your learning today

The five top life threatening causes of chest pain that we must rule out are: ACS/MI; pulmonary embolus; aortic dissection; pneumothorax and pneumonia.

First and foremost a thorough clinical history and examination are the best tests we have to narrow the differential diagnosis.

a, An ECG should be done as soon as possible for patient and carefully assessed for signs of ischaemia or infarction

b, Blood tests that may be useful to rule out life threatening causes of chest pain are a high sensitivity troponin (if the ECG is normal) and a d-dimer (if the pre test probability is appropriately low).

c, An echocardiogram can be helpful in the diagnosis of PE (right heart strain), aortic dissection (intimal flap and pericardial effusion) and ACS/MI (regional wall motion abnormality). A bedside ultrasound can also be used to diagnose pneumothorax.

In order to embed today’s learning further, reflect on what you have learnt and record in your portfolio whether it has had any impact (or is expected to have any impact) on your performance and practice.

Was this a topic that you were confident you knew already? Which parts were new to you? Were there elements that you will use on your next clinical shift.

Dscuss this session with your colleagues – were there people who missed it who you can share the highlights with?

References

  1. 1.
    Connolly C. Induction – Chest Pain – RCEM Learning. RCEM Learning. Published February 18, 2018. Accessed June 6, 2020. https://www.rcemlearning.co.uk/foamed/induction-chest-pain/

Lesson Plan prepared by Iain Beardsell, Consultant in Emergency Medicine, University Hospital Southampton



Cite this article as: Iain Beardsell, "Medical School Lesson Plan – Chest Pain," in St.Emlyn's, September 18, 2020, https://www.stemlynsblog.org/medical-school-lesson-plan-chest-pain/.

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