Friday, 23 March 2007

Types of Chest Pain

Whenever I teach a doctor for the first time and the history is about pain, I always ask various questions about the pain to which I get looks of bewilderment because surely pain is just pain, right???????........Wrong.

There are many different types of pain.

Let me take an example about chest pain. I was recently told a short history about a patient with GI bleeding and chest pain.

The doctor had failed to elicit any further history of the pain.

Questions that should have been asked included:

  • What type of pain? Severe, crushing, squeezing chest pain (cardiac) [Like an Elephant sitting on your chest] or severe ripping/tearing pain going through to the back (dissection), sharp and/or worse on inspiration or moving (pleuritic), superficial or deep pain (superficial may be from skin / muscle or bone).

  • Does the pain radiate any where? To the neck / jaw / arms (cardiac), to the back (dissection), to the abdomen (inferior ischaemia / MI / dissection). Is the pain worse on lying flat and better sitting forwards? (Pericarditic pain).

  • Did the patient suddenly become acutely breathless with chest pain? (Pulmonary Embolism / Pneumothorax / Dissection / Massive AMI).

  • Did the pain come on gradually or suddenly? Gradual pain may be associated with infection / malignancy / unstable angina / chronic and progressive dissection / pleurisy / myositis / shingles. Acute onset pain must always be taken seriously and may signify an MI, PE, Dissection.

  • How severe was the pain? Try to use the Pain Scale, with 1 being minimal pain and 10 being the most severe pain imaginable and 5 somewhere in between. Of course, one person's perception of pain is different to that of another person and so the pain score needs to be individualised. This is useful to use as a guide to assess the severity of the complaint.
  • Was the pain continuous or intermittent? Ischaemic pain may reach a crescendo of severity before continuing or subsiding. Pleuritic pain is by definition not continuous as it tends to occur during deep inspiration and gets easier on expiration. Did the pain come on or get worse with exertion?
  • Did anything make the pain better or worse? Do you have a Nitro Spray? If so, did it make the pain better.
  • Did the patient lose consciousness with the pain? PE, Dissection, Aortic stenosis and severe ischaemia, Massive MI.
  • Was the patient vomiting with this chest pain and have a grey look and sweaty? Very cardiac sounding but of course can occur with dissection or any cause of shock. The 'grey look' and sweatiness are due to catecholamine output. The vomiting tends to occur with MI but this is not a good discriminator.
Other causes of chest pain include a oesophageal spasm type pain which is sometimes indistinguishable from cardiac chest pain. This pain also improves with nitrate or calcium antagonist but a patient will tend to have a normal ECG during such episodes.

Gastro-esophageal Reflux Disease (GERD) may cause a retrosternal, rising, burning type pain and an acid sensation at the back of the throat. Worst cases can cause vomiting. Patients will also suffer from flatulence.

Spontaneous rupture of the oesophagus can cause worsening chest pain (from mediastinitis) and patients may develop swollen upper chest and neck from surgical emphysema of air beneath the skin. Hence a history of patients eating when the pain started maybe important.

Also, sometimes, chest pain is mistaken as abdominal pain especially in the epigastric area and hence, disorders such as peptic ulceration, cholecystitis, pancreatitis, sub-phrenic abscess etc also need to be considered when thinking of pain in the chest.

Of course, other questions such as previous chest pain history e.g. AMI, angina should be questioned about, including Family History. Smoking history, diabetes, hypercholesterolaemia, history of dissection in the family / PE and DVT should also be asked.

In respect of the above, it is not fully comprehensive and is only a guide on the questioning with regards to emergency history taking of chest pain. It is impossible to cover all aspects of chest pain in this short blog.

However, in this case, the patient had ischaemic sounding chest pain and dizziness with tarry stool and haematemesis. It is likely that the profound haemorrhagic shock caused cardiac ischaemia and dizziness which promptly reversed on restoring the circulation with blood. ECG when patient was pain free was normal. There had not been an ECG when the patient had developed chest pain.

CK and Troponin T were normal. However, Troponin T takes time to rise and for current tests, this should be performed at about 6 hours and NOT on admission as the CK and Troponin are likely to be normal despite the patient sustaining myocardial damage.

If pain sounds atypical for chest pain or other serious pathologies then question about back problems as pain in the chest can occasionally be due to radiation from a spinal source to the anterior chest wall. Also, consider other diagnoses such as Syndrome X (ischaemic sounding chest pain but normal angiography studies, Prinzmentals (Variant) angina, Early Shingles (zoster) before the typical dermatomal rash forms. One should also asking about the patient's current mental health state, as sometimes patients with develop pain with no organic cause. Sometimes, in such cases, patients may be suffering depression and as such, this type of pain is termed psychosomatic or somatisation. However, this is a diagnosis by excluding the more serious causes FIRST.

Tuesday, 20 March 2007

UpToDate on PDAs

Today I want to talk about my special love (apart from my family of course !! :) ) .....PDAs.

As I have previously mentioned, PDAs are quite popular in Japan, but I consider that they are under utilised here to some degree.

I have discovered that UpToDate can now be used on the Palm based PDA platform such as the LifeDrive and Palm Treo handheld devices running Garnet OS 5.4.

Unfortunately, having tried to run the software on the
Sony Clie TH55 (Palm OS 5.2) it does not work ! Hence, if you want to use UpToDate you need a newer type Palm.

Below are some photos of my old LifeDrive with UpToDate running. It is great!!

However, Palm based PDAs are going to become extinct in the future, or at least, that is what is being said in the PDA world, with Microsoft Windows Mobile 5 (Pocket PC) taking over with its multi-tasking capabilities.

However, although UpToDate also support the WM5 PPC PDAs and earlier versions, the software (which I have)
does not run on a Japanese language WM5 PDA !!

In fact, after asking for support from UpToDate (which is excellent I might add) they mentioned that UpToDate for Pocket PC does not support '
Chinese Characters'.

So, if you have a Japanese Pocket PC, it would seem that at present, UpToDate will not run either.

My advice would be, if you want to use UpToDate on a PDA, either get a Palm running OS 5.4 or a PDA phone where UpToDate can be accessed via its site on the internet via the PDAs internet browser.

I think that UpToDate is a very good tool for physicians on the ward and now that it is in PDA format, it should become a highly useful tool for the physician who needs a second opinion !