Chest Pain Presentation and Resp Symp - 20231)

Chest pain in primary care
Dr.Danya Gari
Family medicine consultant
Assistant prof.
dmgari@iau.edu.sa
Wednesday, February 14, 2024
Wednesday, February 14, 2024 Presentation title
Learning objectives
 At the conclusion of this activity, students will be able to:

– Recognize different causes of chest pain in primary care
– Evaluate patient with chest pain by history and examination
and imaging if needed.
– Identify patients who need to be referred to ER
– Treat the common causes pf chest pain

 chest pain occurs in 20% to 40% of the general population
during their lifetime.
 1%  primary care visits
 Chest wall pain, reflux esophagitis, and costochondritis are the
most common causes of chest pain in the primary care
population

 Chest wall pain (20%) costochondritis (13 %), At least two of the following findings:
 localized muscle tension
 stinging pain
 pain reproducible by palpation
 absence of cough
 Reflux esophagitis (13 %) Burning retrosternal pain, acid regurgitation, sour or bitter taste in
the mouth; one-week trial of high-dose proton pump inhibitor relieves symptoms
 Gastroesophageal reflux disease [GERD] Burning retrosternal pain, acid regurgitation, sour or
bitter taste in the mouth; one-week trial of high-dose proton pump inhibitor relieves symptoms

 Pneumonia : fever, productive cough, dyspnea, Hx of URTI…
 Pulmonary embolism: dyspnea, prolonged immobilization..
 Psychological (e.g., anxiety, panic disorder)
 In the past four weeks, have you had an anxiety attack
(suddenly feeling fear or panic)?
 Cardiovascular disorders (e.g., acute congestive heart failure, acute
thoracic aortic dissection)
 A 60 year old male develops acute shortness of breath for 1
day. He just returned home from an airline flight that took 10
hours. He also complains of pleuritic chest pain but denies any
other symptoms. He just received the last dose of
chemotherapy for colon cancer last month.. What is most
probable cause of the patient’s chest pain ?
a. Acute MI
b. Spontaneous pneumothorax
c. Pulmonary embolus
d. COPD

SOCRATES 1. History
Site – where is the pain (e.g. central chest)
Onset
 Duration of pain (important when considering angina vs acute coronary syndrome)

 Did it come on suddenly or has it been gradually building?
 What was the patient doing at the time of onset? (exertional / at rest)
Character:
 Aching/crushing – typical of acute coronary syndrome (ACS)

 Sharp pain that’s worse on inspiration (pleuritic) – pulmonary embolus/pneumothorax
Radiation:
 Does the pain move anywhere else?

 Left arm and jaw is typical of ACS
 Radiation through to the back is associated with aortic dissection
 Associated symptoms:
 Respiratory system review
 Cardiovascular system review
 GIT system review

 Time course
– duration – minutes / hours / days / weeks
– Worsening / improving / fluctuating
 Exacerbating/relieving factors:
– Does anything make the pain worse?
– Inspiration (PE / pneumothorax / pneumonia)
– Exertion (ACS / PE / pneumothorax / pneumonia)
– Lying flat (pericarditis
– Movement ( musculoskeletal )
– Does anything make the pain better?
– Leaning forward (pericarditis)
 Severity
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27 year old Indian driver, complains of chest pain for 4 days, associated with fever and rusty
productive cough. His employer is afraid if it was TB.
How can you approach this patient to have a better idea of his disease?
 What would you do next?

2. Physical examination
 Always start with VITAL SIGNS BECAUSE THEY ARE VITAL!!!!!!!

 We need to look for HR, BP, RR, Oximetry, T, BMI
 All indices are important will show us if the patient can continue
in primary setting or should be directly referred to ER
 Unstable patients specially with tachycardia, tachypnea, hyper or
hypotension should go to ER
 Also, low Oximetry. Fever will indicate infection.
 Next, look at the patient. Ill looking, distressed, depressed…
Chest pain
Muscular Pulmonary Cardiac GI Others
PE Panic
ACS GERD
Costochondri LL edema attack
Chest pain radiates to both arms
tis Hypotension
S3 gallop Esophagea
Pneumothorax Psychogenic..
Diaphoresis l spasm
Decreased or diminished Pleuritic chest pain
Muscle air entry
Palpation of tender area reproduces chest pain
Resonant percussion
strain
Tenderness on
chest wall
Pericarditis
Pneumonia
increased vocal
resonance
Dullness to percussion
Aortic
Fever dissection

3. Labs and imaging
ECG
Cardiac
PA chest No orders needed
enzymes
Chest pain
No orders Xray
needed CT

Spiral CT
ECG
PE D-Dimer GERD Panic attack
Costochondritis ACS
Esophageal Psychogeni
Pericarditis spasm c..
Pneumothorax
Muscle strain
Aortic
dissection
Pneumonia

General Management
Chest pain
ER SSRI
PPI
O2
ER
PE ACS GERD Panic attack
O2
Costochondritis
Pneumothorax Pericarditis Esophageal

Psychogenic..
ER spasm
Needle decompression in
2nd intercostal
midclavicular line
Muscle strain Aortic
dissection
Rest the
Pneumonia
muscle
Antibiotics,
NSAIDs macrolides
Topical

a 21 year old male, not known to have any medical illness, comes to the clinic
complaining of unspecific chest pain, for 1-2 month duration, not associated
with cough or fever or any other complain, no history of GI symptoms, he is a
student at the collage, lives alone, his parents in another city, you noticed his
mood is low and he has some financial issues. What would his chest pain
caused by?
 A) Bacterial pneumonia
 B) It is most likely related to his social and psychological status
 C) GERD
 D) Pneumothorax
Respiratory Symptoms

Objectives
 At the conclusion of this activity, students will be able to:

1. Recognize common respiratory symptoms encountered in the
clinic
2. Relate symptoms and clinical findings with possible diagnoses

Cough
Acute Subacute Chronic (>8
(< 3 wks) (3-8 wks) wks)
Life threatening Non- Life threatening

PE Viral URTI
CHF bronchitis
Pneumonia
Acute asthma

Common cold VS influenza
Rhinoviruses, adenoviruses
influenza viruses: Type A, Type B,
Parainfluenza and RSV and Type C

Cough
Acute Subacute Chronic (>8
(< 3 wks) (3-8 wks) wks)
Life threatening Non- Life threatening

PE Viral URTI
CHF bronchitis
Pneumonia
Acute asthma

Acute cough
1. Acute upper respiratory tract infection.
2. Acute lower respiratory tract infection (pneumonia).
3. Acute exacerbation of underlying chronic pulmonary disease.
4. Pulmonary Embolism (PE).

Sub acute cough
1. Post-infection of upper or lower respiratory tract.

2. Angiotensin Converting Enzyme Inhibitors (ACE-I)
medication.
3. Upper airway cough syndrome (it is related to allergic, non-
allergic or vasomotor rhinitis, naso-pharyngitis, & sinusitis.
i.e postnasal drip
4. Bronchial Asthma
5. Gastroesophageal reflux disease
Other causes
1. Chronic bronchitis (COPD, eosinophilic)
2. Bronchiectasis
3. Neoplasm
4. Interstitial lung disease (ILD)
5. Lung abscess
6. Obstructive sleep apnea (OSA)
7. Tracheobronchial foreign body or mass
8. Nasal polyps
Chronic cough
• It is reported by 10–20% of adults, commoner in females and

obese.
• Cough accounts for 10% of respiratory referrals to secondary
care.
• Most patients present with a dry or minimally productive
cough.
• The presence of significant sputum production usually indicates
primary lung pathology.
Common causes of chronic cough
 upper airway cough syndrome (UACS)post nasal drip. chronic

rhinosinusitis, allergic rhinitis, and nonallergic rhinitis,
 Asthma
 nonasthmatic eosinophilic bronchitis, It does not respond to
inhaled bronchodilators, but should respond to inhaled
corticosteroids.
 gastroesophageal reflux disease (GERD) empiric therapy for at
least eight weeks in conjunction with lifestyle changes such as
dietary changes and weight loss
MCQ
 not likely to be seen in common flu?
 A) Fever
 B) blocked nose
 C) sore throat
 D) Rhinorrhea

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Cough in children
 Chronic cough in children is defined as cough lasting more than four weeks
 observation for one to two weeks may be used in patients with a
nonspecific cough.
 asthma, protracted bacterial bronchitis
 UACS is rare in children younger than six years, and antihistamines and
decongestants are not recommended
 GERD does not seem to be as common in children, and empiric proton pump
inhibitors are not recommended in the absence of a specific diagnosis.

Sputum:
 Amount: N amount < 100mls of mucus/day
 Color: N, clear & white mucus
 Smell: N, not smelly
Ex: chronic large amount of purulent sputum may suggest
bronchiectasis while acute one may indicate lobar
pneumonia.
Ex: foul-smelling purulent sputum may indicate lung
abscess with anaerobic infection
Ex: pink frothy secretions occurs in pulmonary edema

MCQ
 1. 60-year-old lady complains of dry cough that started 1 month
back, not associated with chest pain or dyspnea, no Hx of GI
symptoms or Cardiac symptoms. She takes oral captopril (ACE
Inhibitor) for her hypertension for 10 years. How would you manage
her cough?
 A) Trial of high dose PPI
 B) Order a spirometry
 C) Refer to pulmonary specialist
 D) Change her antihypertension medicationz

Hemoptysis:
 Commonest cause is acute infection like exacerbation of copd
but other serious causes should be investigated
 Other causes: PE, Bronchogenic ca., pul TB, bronchiectasis,
lung abscess
 Pulmonary hemorrhage from any cause like: Goodpasture’s
syndrome or rupture of a mucosal blood vessel after a vigorous
coughing
 Rusty sputum (when purulent sputum is mixed with blood) eg:
lobar pneumonia
MCQ
Dyspnea
 Chronic dyspnea is shortness of breath that lasts more than

one month
 The etiology of dyspnea is multi-factorial in about one-third of
patients.
 To clarify dyspnea, the patient history should address the
onset, character, duration, severity, periodicity, and
progression of symptoms. Aggravating and relieving factors
also should be noted.

Dyspnea

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Case
 A 67-year-old man comes to your clinic for his annual
appointment concerned about increasing shortness of breath. A
year ago he was able to walk up the stairs to his apartment
without difficulty, but now he has difficulty walking one block.
He has a 70 pack-year smoking history, and several previous
attempts to stop smoking have been unsuccessful.
• Does the patient require urgent intervention?

MCQ
MCQ
Thank you

Chest Pain Presentation and Resp Symp - 20231)

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Chest pain in primary care

 At the conclusion of this activity, students will be able to:

Wednesday, February 14, 2024 Presentation title

Wednesday, February 14, 2024 Presentation title

 localized muscle tension

 pain reproducible by palpation

Wednesday, February 14, 2024 Presentation title

Wednesday, February 14, 2024 Presentation title

 Duration of pain (important when considering angina vs acute coronary syndrome)

 Aching/crushing – typical of acute coronary syndrome (ACS)

 Does the pain move anywhere else?

Wednesday, February 14, 2024 Presentation title

 What would you do next?

Wednesday, February 14, 2024 Presentation title

 Always start with VITAL SIGNS BECAUSE THEY ARE VITAL!!!!!!!

Muscular Pulmonary Cardiac GI Others

Wednesday, February 14, 2024 Presentation title

Muscular Pulmonary Cardiac GI Others

Wednesday, February 14, 2024 Presentation title

Muscular Pulmonary Cardiac GI Others

Pneumothorax Pericarditis Esophageal

Wednesday, February 14, 2024 Presentation title

Wednesday, February 14, 2024 Presentation title

 At the conclusion of this activity, students will be able to:

Wednesday, February 14, 2024 Presentation title

Life threatening Non- Life threatening

Wednesday, February 14, 2024 Presentation title

Wednesday, February 14, 2024 Presentation title

Life threatening Non- Life threatening

Wednesday, February 14, 2024 Presentation title

Wednesday, February 14, 2024 Presentation title

1. Post-infection of upper or lower respiratory tract.

• It is reported by 10–20% of adults, commoner in females and

 upper airway cough syndrome (UACS)post nasal drip. chronic

Wednesday, February 14, 2024 Presentation title

Wednesday, February 14, 2024 Presentation title

Wednesday, February 14, 2024 Presentation title

Wednesday, February 14, 2024 Presentation title

 Chronic dyspnea is shortness of breath that lasts more than

Wednesday, February 14, 2024 Presentation title

Wednesday, February 14, 2024 Presentation title

Wednesday, February 14, 2024 Presentation title

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