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Hello and welcome to the second video in my series on, um, respiratory presentations. So this is a presentation is gonna be covering the symptom breakdown of chest pain as a clinical presentation. Uh, so similar to my last video, which is going to run through a quick framework and how to look at chest pain, Um, in the history. And then what sort of the French was we can consider? I've also thought about bit more about what investigations you may consider to determine different causes. And then I've got a few questions at the end of UK studies for you guys to practice. Um, as always, I'd love to get feedback so that I can always improve what I'm doing. Um, thank you a fortune. This is likely to be a familiar framework for quite a few people. Um, if you can remember the guy on the right. So this is the Socrates, or this is what I prefer to use. Socrates, you may use, Prefer to use quitters or another framework, but essentially as long as what you're doing with your, um, questioning is ascertaining the nature of the pain. So what's the character? The pain does it resemble cardiac pain that resemble GI pain? Um, the location of the pain. Is it in multiple locations in one location? Does it radiate anywhere? Um, is it poorly localized? Is it well localized? Any associate triggers. So is it worse than by exertion? You're thinking more about ischemic cardiac pain if it's worsened by sort of coughing, sneezing, inspiration. Or you're thinking more about diuretic, um, potentially, even most politically to chest pain. And you also want to know about whether this is acute or chronic chest pain. Because once again, that's also gonna shift your, um, sort of thinking regarding to this presentation. And you also want to know about the severity of the chest pain to to really think about how is this impacting your patient? So this is just a short slide covering sort of. Some of the main called clinical features associate with some of the systems involved in chest pain. So I've gone for a more anatomical sort of system today, primarily because I find an easier way to think about chest pain. If you just think, actually, what are the organs present in thorax? And how can disease processes affect these organs? to produce, um, clinical symptoms. And so, uh, sort of a description of the different presentations. You may or may not know this. Um, the likely it is. You probably already know they're the most important clinical features thinking about chest pain. So if you're thinking about cardiac versus respiratory or muscular skeletal Um, what I haven't put on there, what is quite important to consider is psychogenic or psychological chest pain as well. So you also wanna think more holistically. It may not be due to organic disease, but potentially, it could be due to some anxiety disorder. And so, thinking about the first of our systems with respiratory based chest pain, I prefer to think in, um, two ways. When you think about the respiratory system, obviously for the airways, you know your trachea, which is connected to your larynx, and then it goes on to from your bronchi at the Carina and your great bronchioles alveolar lying in your lungs. And so when thinking about chest pain, you can think about disease. Process is affecting these different areas, so the lungs are overlying by pleura, so the pleural membrane over lie the lungs. You got your visceral pleura, and you're gonna prior to your eye as it reflects off the Ontario thoracic wall. And so you can think about pleural disease. So pleural disease being either pneumothorax we have leaking into the pleural cavity, or pleural effusions, where you have fluidly filling the pleural cavity so you can think about pneumothorax and pleural effusion. Or maybe just pleurisy and inflammation of the pleural pleural membrane as potentially some causes of respiratory chest pain, especially acute chest pain to consider. And I'm thinking about parenchymal disease, so disease are actually affecting the actual lung itself. And so you can think about pneumonias or somebody with either viral or bacterial infection of the parenchyma presenting with subacute chest pain, cough fever, mucoprotein, sputum. You can think about vascular um, obstruction. So if you've got, uh, an embolus, which is essentially blocking the blood flow from the pulmonary arteries towards the lungs and you've got pulmonary embolism, you can consider this is a potential cause of sudden onset pleuritic chest pain. Um, to keep the, uh, tachycardia with somebody with history of DVT, somebody with risk factors for P. Maybe they've had recent surgery on malignancy or family history of thumb Ophelia. So that's sort of the way I like to think a bit. So just been wine atomical thinking about the pleural membrane thinking about the lung. Parenchyma Uh, yeah, the pleural membrane. I'm thinking about the lung parenchyma primarily and then thinking about cardiovascular, um, cause of chest pain. So you can consider, um, with cardiovascular chest pain. So is there an issue with the blood supply to the MYOCARDIUM? So have they got some form of acute coronary syndrome? Whether this is unstable angina or somebody with, uh, non ST elevation myocardial function or myocardial infarction with ST Elevation, um, so you want to consider your classical presentation for that must always be ruled out in any patient with acute chest pain. Um, and then you can consider whether they have any pericardial disease. So once again, pericarditis caused by inflammation of pericardium this can be because of infection can be because of a complication of myocardial infarction can be because of autoimmune disease. So, um, but the clinical features generally includes off sharp stabbing, social chest pain, um, shortness of breath, classically with pericarditis. The shortness of breath is, um or the chest pain is worse. when you're lying down. Um, and it's relieved when you sit forward. You can also think about David Angina So classical, uh, features stable angina of the ischemic chest pain, which is relieved by rest or really by G T N u M and worsened by exertion. And then you must always rule out use that section to consider risk factors for rupture of the iota. Um, so you may Maybe they have a history of Marfan's or family history of Marfan's syndrome. Maybe look at history, Danlos syndrome, Turner syndrome or some some other clinical presentation. But that's a very acute differential and a life threatening differential to really consider with your musculoskeletal causes of chest pain. Um, you just need to really think about some of your intercostal muscles. Your ribs. Um, so if you're costalcondritis, um, and this can cause sharp or localized chest pain, typically with pain recreated movement may be recreated and coughing because, obviously, as you you cough, you're going to generate some movement of thoracic cavity, which can produce chest pain as well. A fractured rib or soft tissue injury or trauma to the chest would be important to consider, So musculoskeletal chest pain is important differential, especially for pleuritic chest pain. Um, and if they have sort of norther clinical features or their spirit examination is normal, and you know they have pain, which is recreated on par patient of the affected area. You may be leaving more towards somebody that muscular Stickley. The chest pain with gastrointestinal based differentials. You can really consider whether justice a patient with potentially pancreatitis, So obviously you think more about pancreatitis with the acute abdomen presentation. But you shouldn't forget that the pancreas can also present with a big gastric chest pain, which can potentially sort of be in that region of essentially near the board of the thoracic and abdominal cavity. So you may have to consider pancreatitis, especially in a patient, the significant alcohol use, history or misuse history, Um, or somebody with previous school stones disease. Um, it is important to consider, um, as a differential. So somebody with nausea and vomiting and severe dehydration and acute gastric pain radiating to the back, you may need to consider pancreatitis. You can consider gastroesophageal reflux disease. Somebody with them, maybe obesity. Diagnosis of hiatus, Hernia. Uh, so this longer term history of sort of so symptoms of dyspepsia. So, you know, acidic taste in the mouth retrosternal burning chest pain associated with food. Maybe associate more fatty foods or spicy foods. Um, maybe worse on lying down, you can consider this potentially to be some of the gastroesophageal reflux disease gall bladder disease can present quite similarly to somebody with the right level of pneumonia. Um, because obviously, when you think about abdominal pain, um, sort of gallbladder disease typically presents in the right upper quadrant. Um, and the, uh, the rapper quadrant isn't really too far off from of the lower edge of the lung. So the lung quite extends. Quite quite. I mean, fear early as well. So you need to consider potentially go bad disease, which may or may not be associated with food. They may have other features of drawn this, um or sort of features of fever. If they have a few quality status or something like that. Um, gallbladder disease should be important to consider, especially in, um somebody who's obese or a patient with potentially other risk factors for about a disease. And, um, and then you can consider a peptic ulcer so peptic also somebody with sort of a variant presentation, competent as an acute emergency with perforation, um, and peritonitis. And this can cause sort of generalized abdominal pain, nausea, vomiting, somebody who's very ill. Um, some of the bridges abdominal part patient who have really intense abdominal musculature, which is tense because of the pain. Or you can consider somebody who maybe would sort of more chronic sort of similar presentation to maybe chord with dyspepsia and, um, pain. And they're sort of restaurant sternal region, um, or you can present as somebody with an acute upper GI hemorrhage or bleed if there's some ulceration into a significant blood vessel. Also, uh, I was also ate into the splenic artery or, um, actually to the dean Watery. Consider some massive upper GI hemorrhage. Um, a presentation of the upper GI hemorrhage as well. So you can see that there's a wide variety of gash into standard differentials to really consider, um, as a cause of chest pain and finally just thinking about psychogenic cause of chest pain. Somebody with a history of chest pain may be more chronic. Chest pain. No significant cardiovascular risk factors. Um, their cardiovascular respiratory examination is normal. Uh, investigations are all normal. You may consider patient who might have a psychological cause of chest pain nonorganic cause maybe generalized anxiety disorder and somebody with more of a chronic history of diffuse worrying, Um, a significant period of time or most days of the week. Um, a patient may be having panic attack disorder where they have sudden episodes of, uh, severe anxiety fear hyperventilation, epigastric, chest pain, palpitations. Um, you can also consider social phobia if this is recreated in social environments or core a phobia if they're unable to leave their house or home traveling on, um, public transport or going to the public, um, into crowded spaces. And this recreates the same symptoms as well. So psychogenic causes are also very important to consider. So I've sort of put a few of the red flags to really consider for acute chest pain. You can't miss a patient presenting with acute coronary syndrome attention with thorax pulmonary embolism, a few ultra that section. These are some of the life threatening complications. I haven't actually put up there. Sort of. The rupture can also be a cause, um, of chest pain, which is a life threatening to consider And so just take a moment to think about what investigations you would order in a patient with an acute episode of chest pain. What would you consider, um, to be important investigations? So the main investigations I think about and when I think about investigation, they try to keep systematic. So bedside tests, blood tests and imaging, uh, or any other special tests of diagnostic tests as well. So bedside tests, really, that would be classed investigations. But more so, observations are very important to consider. You want to do frequent observations, calculating the new score or a few score depending upon whether this is another pediatric patient. Um, this is important because a new school enables you to track how it will, how severe the illnesses that's affecting this person. It also led to audio management. When or when do you may When When you When you may. You want to have more senior input much more quickly. Um, you may consider an A B G of thinking. This is somebody with potentially sepsis because of pneumonia. Unlikely? Um, or not really unlikely, but you can't consider that or a V B G as well e. C. G is very important in chest pain. So especially for cardiac, of course, is you can consider whether or not there's some classical cardiac changes. So there's any ST Elevation. There's any new onset like bundle branch block if there's any T wave inversion and pathological Q waves. But you should also consider that E. C G changes can occur with non cardiac problems so you can have e c G changes in pulmonary embolism, for example, um, so you need to consider that and take that into account with the clinical picture of their symptoms and how long the chest pain has been present for and the character of their chest pain. Blood should include a full blood count for any white cells were thinking about infection. Thinking about hemorrhage like a dissection may be looking at their, um, replace cell count may be useful, although potentially their red cell count may not have dropped yet. Using these for renal function, um, liver function tests important that you can go at rapid quadrant pain. Maybe this is somebody with hepatitis or gallstone disease. Potentially, Um, CRP is important to consider as well, just as a cute phase reactant really of inflammatory problems. High sensitivity Troponin is very important. You you need to bear in mind high sensitive troponin test should be taken into account based on how long has that pain been present for, um, the idea that you should bear in mind that troponin test can be raised because of other causes like pulmonary embolism, pericarditis, myocarditis or arrhythmia. So it's not only raised in my cardio infarction, but if the sensitivity of the the troponin testers were greater than the 99 percentile, um, there's a significant rise. You may be leaning more towards a patient having a cardiac called especially in acute coronary syndrome, especially if the African features you may consider an amylase if you're thinking about pancreatitis as well. Um, Septic, you may think about blood cultures and other key cultures. Urine cultures of the sources of infection imaging may include chest X rays, a standard to think about complications of my card in function, or just looking for floral diseases like pneumothorax or pop your infusions, uh, consolidation associated with global pneumonia. You can't consider an echo if you're strongly convinced about cardiac functioning, Although I don't I'm not too sure if that's a regular investigation to consider. And then you can consider whether or not if you're thinking about P, do you need a Dedham CTP a another investigations and just sort of a tip to bear in mind with any diagnosis you're thinking about. Always think about a severity scoring system. So if you're thinking about pneumonia, use the crab 65 scoring system. Thinking about pulmonary pulmonary embolism, You use the well scoring system if you're thinking about end stemi considering Grace assessment, grace scoring system to look at the severity as well, and that can also aid in management. Finally, I've got a few cases. So just running through this first case about 22 year old male presenting to the any department with acute onset chest pain he was running and then suddenly felt our breath and had chest pain on the right side of his chest. He does not have a history of any prior lung disease and is otherwise fit in well, pain is pleuritic in nature. What is the most likely diagnosis and what is the recommended management so you can take him into pause and then come back to the video. The most likely diagnosis is a patient of spontaneous primary pneumothorax. This is because he hasn't got any significant history of any secondary lung diseases or chronic lung diseases like, um, some other form of COPD asthma or anything else like that. Pain is Politican Nature's acute answer, and it's unilateral on one side of the chest. He's young male, so he's sort of the optimal, um, patient population to present with this sort of presentation. And so this is, uh, most likely diagnosis is not secondary with thorax once again because he has no prior history of lung disease. It's not pulmonary embolism because he hasn't got any significant risk factors for minimalism. Q. Conroe syndrome doesn't present unilaterally on one side, um, or maybe potentially to present similarly, but the pain is pleuritic in nature rather than ischemic in nature, he would still consider and rule out any acute coronary syndrome. Pericarditis is unlikely diagnosis in this setting, And so I've primarily included this case study to really consider the fact that panic attack disorder can present um, or psychogenic conditions kinda present with chest pain. So chest pain does not have to be organic in nature, so don't fall into the trap of thinking that all chest pain has to be organic in nature. Due to some pathology, it can be due to psychological problems as well. Um, so considering generalized anxiety disorder, social phobias, Ankara phobias, panic attack disorders, another psychiatric conditions as presentations of nonorganic chest pain is very important to consider. And, um, this doesn't mean that you should disregard everyone's just being a state psychological nature. You should fully investigate and rule out serious, um, pathology and serious causes. But once you're confirmed and once you're confident or you've ruled out, um, most of the organic problems of chest pain, then you may want to consider psychogenic chest pain as a key differential as well. Finally, I would just like to say thank you, Fortune Video. Once again, this video has been slightly longer than anticipated. Hopefully, the other video shouldn't be as long as this have. I just want to make sure that this video of chest pain is quite thorough because it's a very common symptom. Um, and I would just like to give you guys more of a systematic framework for really approaching this. You may already have known a lot of this. Um and this could have just been a refresher for you. However, you found this useful. Please do. Let me know if I've made any mistakes. Once again, please let me know. And if you have any other topics you want me to consider, um, fill in a feedback form and let me know down below. Thanks for watching guys.