Clinical Opal - Heather presents with central chest pain
Heather who is 55 years old presents to you today complaining of a dull ache in the central chest region which she has had on and off over the last 2 weeks. She is a school teacher at the local high school and is looking forward to an early retirement where she can focus on being a grandmother to her 4 young grandchildren.
Heather reports the pain to be 6/10 and is not experiencing any radiation nor is the pain associated with nausea, diaphoresis, or shortness of breath. The pain is not relieved with paracetamol or ibuprofen and she is unable to identify any triggers.
She is not currently taking any regular medications, but did take Sertraline 50mg/day for a period of depression a few years ago. She takes paracetamol for back pain on occasion if she feels she needs it.
You perform an assessment:
HR: 87
RR:16
BP:115/58
Temp 36.7
She appears tired but she is engaging in conversation appropriately and has an excellent memory.
You have asked the practice nurse to perform an ECG and you will get Heather to have her bloods taken today.
What are four possible non-cardiac factors that you would consider?
Answer
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Anxiety or stress-related chest discomfort
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Gastroesophageal reflux disease (GERD)
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Musculoskeletal pain
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Respiratory condition (e.g. pneumonia, pleuritis)
Undifferentiated chest pain poses a diagnostic challenge for health professionals, as it requires a thorough investigation to identify the underlying cause. Some examples of this approach are as follows.
History taking:
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Thorough exploration of chest pain characteristics, including onset, duration, and any associated symptoms.
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Inquiry about recent illnesses, stressors, or changes in physical activity.
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Review of systems to identify potential non-cardiac causes.
Physical Examination:
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Vital signs, with a focus on blood pressure, heart rate, and respiratory rate.
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Comprehensive cardiovascular assessment, including auscultation for murmurs and palpation of pulses.
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Examination of the respiratory and gastrointestinal systems to rule out non-cardiac causes.
If cardiac causes are identified, appropriate cardiac medications and referral to cardiology is warranted. If non-cardiac causes are suspected, symptomatic treatment, lifestyle modifications, and further specialty referrals as needed.
Undifferentiated chest pain requires a comprehensive and systematic approach to identify the underlying cause. Regular follow-up and patient education are essential components of care for individuals presenting with undifferentiated chest pain.
Further learning and references
Update your skills on the management of undifferentiated chest pain in this webinar focused on a range of patient case studies and application of the latest clinical guidelines:
- Emergencies in General Practice
- Undifferentiated Chest Pain: Diagnosis, Treatment, and Emergency Response
References
- The assessment and management of chest pain in primary care: A focus on acute coronary syndrome
- Hoorweg BB, Willemsen RT, Cleef LE, Boogaerts T, Buninx F, Glatz JF, et al. Frequency of chest pain in primary care, diagnostic tests performed and final diagnoses. Heart. 2017;103:1727–32.
- Chest pain in daily practice: occurrence, causes and management
Grace Larson, RN, BN, CertIV(TAE), GradDipClinNurs(PaedCritCare), MAdNursPrac(PaedCritCare), has extensive experience in paediatric nursing, with 13 years in Paediatric Intensive Care Units (PICU). She’s published journal articles in the specialty area of pain and sedation in PICU, and has presented at national and international conferences on the area of pain and sedation in paediatrics. Grace has previously worked with the ACCCN delivering Paediatric Advanced Life Support in Victoria, bringing a wealth of experience into her clinical teaching on paediatric resuscitation. She has also consulted with NSW Health on quality and safety delivering within PICU, and has been contracted with the ANMF to develop nursing programs for nurses who require additional education as part of their practice requirements.
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