Chest Pain
Chest pain is a symptom of discomfort or pain in the thoracic region that may originate from cardiac, pulmonary, gastrointestinal, musculoskeletal, or psychogenic causes, requiring prompt evaluation to exclude life-threatening conditions.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Musculoskeletal / Costochondritis | Localised, reproducible on palpation, worse with movement [3] | 「撳落去會唔會痛？郁身體嗰時痛唔痛？」PE: tenderness over costochondral junction | ~35% |
| GERD | Burning, worse lying flat/post-meal, relieved by antacid [1] | 「食完嘢之後有冇覺得胸口好似火燒咁？瞓低會唔會辛苦啲？」 | ~20% | |
| Stable angina / IHD | Retrosternal tightness on exertion, 2–10 min, relieved by rest [1][2] | 「行路或者上斜嗰陣有冇覺得胸口好似有嘢壓住？停低休息會唔會好返？」 | ~10% | |
| Serious Not To Miss | Acute coronary syndrome (ACS) | Prolonged ( > 20 min) crushing pain at rest, diaphoresis, troponin rise [2][4] | 「痛有冇持續超過20分鐘？有冇成身汗、覺得好似就嚟死咁？」 | ~3% |
| Pulmonary embolism | Pleuritic pain + dyspnoea + haemoptysis ± unilateral leg swelling [4][6] | 「有冇突然間氣促加埋胸口痛？有冇咳血？有冇隻腳腫？」 | ~1% | |
| Aortic dissection | Sudden maximal tearing pain radiating to back, BP difference between arms [1][4] | 「痛係一開始就最勁？有冇撕裂嘅感覺去到背脊？」PE: inter-arm BP difference > 20 mmHg | <1% | |
| Tension pneumothorax | Sudden pleuritic pain + SOB; hyper-resonance on percussion [3] | 「有冇突然間一邊胸口好痛加上好唔夠氣？」PE: absent breath sounds, tracheal deviation | <1% | |
| Pitfalls | Herpes zoster (pre-rash) | Unilateral dermatomal burning pain, may precede vesicles by days [3] | 「痛係唔係淨係一邊？有冇出過水泡或者紅疹？」PE: dermatomal vesicular rash | ~2% |
| Pericarditis | Sharp pain radiating to trapezius ridge, relieved sitting forward, may have viral prodrome [1][4] | 「坐直身或者趴前會唔會好啲？之前有冇感冒？」PE: pericardial friction rub | ~1% | |
| Masquerades | Panic disorder / Anxiety | Chest tightness + hyperventilation + paraesthesia; no cardiac RF; situational triggers | 「你嗰陣有冇覺得心跳好快、手腳痺、好驚？平時有冇特別緊張嘅情況？」 | ~10% |
| Anaemia | Exertional chest discomfort in the presence of pallor, fatigue | 「有冇覺得特別攰、面青？有冇經血過多或者大便黑色？」 | ~3% | |
| Trying to Tell Me Something? | Health anxiety / Hidden agenda | Recent bereavement from heart disease, fear of cancer, stress at work/home | 「你身邊有冇人最近有心臟病嘅問題？你最擔心呢個痛係咩？」 | ~10% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生，今日由我同你傾吓。你可唔可以話我知你今日嚟睇醫生最主要想處理啲咩？」("Hello, I'm Dr X, can you tell me the main thing you'd like to address today?") | Scores interpersonal marks; establishes patient-centred tone. Sets "one main RFC" early. |
| 0:30–2:30 | HPI using SOCRATES + red flags | 「嗰陣痛喺邊度？」「痛係點樣嘅感覺？好似壓住定刺住咁？」「有冇痛去手臂、頸或者背脊？」「幾時開始？做嘢嗰時定休息都痛？」「通常痛幾耐？」「有冇嘢令到佢舒服啲或者辛苦啲？」「有冇氣促、出汗、作嘔、暈？」 | Structured SOCRATES avoids missing discriminators. Red flags (sweating, syncope, radiation to back, rest pain, SOB) separate ACS / dissection / PE from benign causes. |
| 2:30–3:30 | Risk factors, PMH, drug Hx, FH, social Hx | 「你有冇高血壓、糖尿、膽固醇高？」「屋企人有冇心臟病或者中風？有冇早過55歲？」「你有冇食薄血藥或者其他藥？」「有冇食煙、飲酒？」「做咩工作？壓力大唔大？」 | Captures CV risk factors critical for pre-test probability. Drug history may reveal aspirin / NSAID / OCP (PE risk). Occupation/stress for biopsychosocial. |
| 3:30–4:15 | ICE (Ideas, Concerns, Expectations) | 「你自己覺得呢個痛可能係咩嚟？」(Ideas) 「你最擔心嘅嘢係咩？」(Concerns) 「你今日最希望我幫到你啲咩？」(Expectations) | ICE is a dedicated CRF question. Many students forget to ask explicitly. Uncovers hidden agenda, e.g. "My father just died of a heart attack." |
| 4:15–5:00 | Targeted systems review + functional impact | 「有冇腳腫？有冇隻腳特別腫？」「有冇咳血？」「有冇胃痛、反酸、食嘢落唔到？」「呢個痛有冇影響你返工或者瞓覺？」 | PE (unilateral leg swelling), GERD, MSK clues. Functional impact = social problem for biopsychosocial. |
| 5:00–5:30 | Summarise and check understanding | 「等我總結吓：你最近幾個禮拜做嘢嗰時胸口痛，痛去左手，休息之後好返…我有冇講漏或者講錯？」 | Demonstrates summarising skill; corrects any misunderstanding. Direct interpersonal marks. |
| 5:30–6:00 | Safety net + empathic close | 「我明白你好擔心，我哋會幫你做吓檢查。如果你返去之後胸口痛加劇、痛多過20分鐘、或者覺得透唔到氣，要即刻叫白車或者嚟急症室。」「仲有冇嘢想問我？多謝你今日嚟！」 | Safety-net language is essential in chest pain. Empathic closing scores interpersonal marks. |
Uncovering the hidden agenda: The RFC is NOT always "chest pain." Ask early 「你今日最主要想處理啲咩？」. The patient may have come because a relative just had a heart attack (fear → health anxiety), or they want a sick leave letter, or they stopped medications. Loop back to ICE to confirm the hidden reason.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Site | Where exactly do you feel the pain? | 「痛喺邊度？可唔可以指畀我睇？」 | Retrosternal → cardiac/oesophageal; localised one point → MSK [1][2] | One-finger point → less likely cardiac [3] |
| Character | What does the pain feel like? | 「痛係點樣㗎？好似壓住、刺住、定撕裂嗰種？」 | Constricting/heavy = angina; tearing/ripping = aortic dissection; sharp/pleuritic = PE/pericarditis [1][2] | ACS vs dissection vs PE |
| Radiation | Does the pain go anywhere else? | 「痛有冇去其他地方？例如手臂、頸、牙骹、背脊？」 | Radiation to jaw/left arm = IHD; interscapular/back = aortic dissection; trapezius ridge = pericarditis [1][4] | ACS; aortic dissection; pericarditis |
| Onset / Duration | When did it start? How long does each episode last? | 「幾時開始痛？每次痛幾耐？」 | 2–10 min relieved by rest = stable angina; > 20 min or at rest = ACS; sudden maximal at onset = dissection/PTX [2][5] | Stable angina; ACS; dissection; PTX |
| Exacerbating | What brings on the pain? | 「做咩嘢嗰時會痛？行路、上樓梯、食嘢、深呼吸？」 | Exertion = angina; inspiration = pleuritic (PE, PTX, pericarditis); eating/lying flat = GERD [1][2] | IHD; PE; GERD |
| Relieving | What makes it better? | 「有冇嘢令到佢舒服啲？休息？食胃藥？坐起身？」 | Rest/GTN = angina; sitting forward = pericarditis; antacid = GERD [1] | Differentiates angina from GERD/pericarditis |
| Associated Sx | Any sweating, nausea, breathlessness, dizziness? | 「有冇出汗、想嘔、氣促、暈？」 | Diaphoresis + nausea + angor animi = MI [1][2] | ACS / massive PE |
| Red flag – syncope | Have you ever fainted or nearly fainted? | 「有冇暈低過或者差啲暈？」 | Syncope → massive PE, aortic dissection, arrhythmia [4] | PE; dissection; arrhythmia |
| Red flag – haemoptysis | Have you coughed up any blood? | 「有冇咳血？」 | Haemoptysis → PE [4][6] | Pulmonary embolism |
| Red flag – leg swelling | Any swelling in one leg? | 「有冇隻腳特別腫或者痛？」 | Unilateral leg swelling → DVT/PE [6] | PE |
| RF – HTN/DM/lipids | Do you have high BP, diabetes, or high cholesterol? | 「你有冇三高？高血壓、糖尿、膽固醇高？」 | CV risk factor assessment, pre-test probability for CAD [2][7] | IHD |
| RF – Smoking | Do you smoke? How many per day? | 「有冇食煙？一日幾多支？食咗幾耐？」 | Major modifiable CV risk factor [2] | IHD; aortic dissection |
| Family Hx | Any heart disease or sudden death in your family before age 55 (male) / 65 (female)? | 「屋企人有冇人試過心臟病、中風、或者好後生就去咗？」 | Early death < 55 M / < 65 F = positive family history for premature CAD [7] | IHD |
| Drug Hx | What medications are you taking? Any blood thinners? OCP? | 「你而家食緊咩藥？有冇食避孕藥或者荷爾蒙藥？」 | OCP → PE risk; aspirin/statin compliance for IHD [6] | PE; IHD management gap |
| Social / Functional | How does this affect your daily life and work? | 「呢個痛有冇影響你返工、做運動或者日常生活？」 | Functional impact = social problem in biopsychosocial [CRF] | Disability, sick leave |
| Psych / Stress | Are you under stress or feeling anxious? | 「你最近壓力大唔大？有冇好擔心或者瞓得唔好？」 | Panic disorder mimics chest pain; anxiety as hidden agenda | Panic attack; health anxiety |
| Reproduc. of pain | Can you reproduce the pain by pressing on your chest? | 「如果我撳你個胸口，會唔會痛返？」 | Reproducible on palpation → costochondritis/MSK [3] | Costochondritis |
Case Report Form Answer Builder
- State: "Chest pain for [duration]"
- High-yield points to capture:
- SOCRATES (site, onset, character, radiation, associated symptoms, timing, exacerbating/relieving, severity)
- Red flags asked and negative findings documented
- CV risk factors (HTN, DM, hyperlipidaemia, smoking, family Hx)
- Relevant negatives: no haemoptysis, no leg swelling, no syncope, no fever
- Likely examples: "Worried about heart attack after father died of MI last month," or "Chest pain interfering with work and daily activities," or "GP referred for further investigation of chest pain."
- Phrase as the patient's own reason, not the disease: e.g. "Patient came because he is worried this chest pain may be a heart attack like his father's."
| Component | Example Wording |
|---|---|
| Ideas | "Patient thinks the chest pain may be due to a heart problem / thinks it's just muscle pain." |
| Concerns | "Patient is worried about having a heart attack / worried about dying suddenly." |
| Expectations | "Patient hopes for reassurance and a check-up / ECG / referral to a specialist." |
- In a typical FM station: Stable angina pectoris if exertional chest tightness relieved by rest in a patient with CV risk factors [1][2].
- If rest pain / prolonged: ACS (unstable angina / NSTEMI).
- If young, low risk, reproducible: Costochondritis or GERD.
- Minimum supporting evidence: typical SOCRATES pattern + ≥ 2 CV risk factors.
| DDx | One Key Discriminator |
|---|---|
| GERD | Burning retrosternal pain, worse lying flat, relieved by antacid, not exertion-related [1] |
| Musculoskeletal / Costochondritis | Localised sharp pain, reproducible on palpation, worse with movement [3] |
| Panic disorder | Episodic chest tightness with hyperventilation, paraesthesia, palpitations, situational trigger, no cardiac RF |
(If the stem suggests acute/severe presentation, swap in ACS, PE, aortic dissection.)
| Domain | Example |
|---|---|
| Biological | Uncontrolled hypertension / undiagnosed ischaemic heart disease requiring investigation |
| Psychological | Anxiety about heart disease / fear of sudden death / health anxiety triggered by family bereavement |
| Social | Inability to work / exercise due to chest pain; impact on family role; financial stress from investigations |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports |
|---|---|---|---|
| Stable angina / IHD | No reliable specific sign in brief FM station; best clue: xanthomata around eyes/tendons OR S4 gallop | Inspect periorbital skin, Achilles tendon; auscultate apex with bell | Xanthomata indicate hyperlipidaemia → ↑ pre-test probability for CAD [2][7] |
| ACS | Diaphoresis, new S3/S4 gallop, hypotension | Inspect for sweating; auscultate heart; measure BP | Acute haemodynamic compromise supports acute MI [4] |
| Aortic dissection | Inter-arm blood pressure difference > 20 mmHg | Measure BP in both arms simultaneously | Indicates involvement of subclavian artery by dissection flap [4][8] |
| Pulmonary embolism | Unilateral calf swelling/tenderness (DVT sign) + tachycardia | Inspect and measure bilateral calf girth; measure HR | DVT is source of PE; tachycardia reflects RV strain [6] |
| Costochondritis | Reproducible tenderness on palpation of costochondral junction | Press on the parasternal area | Pain reproduced = MSK origin; cardiac pain is NOT reproducible [3] |
| GERD | Epigastric tenderness (non-specific) | Palpate epigastrium | Tenderness is supportive but not diagnostic; GERD is largely a clinical diagnosis |
| Pericarditis | Pericardial friction rub | Auscultate left sternal edge with diaphragm, patient leaning forward | Pathognomonic scratchy 3-component sound [4] |
| Pneumothorax | Absent breath sounds + hyper-resonant percussion on affected side | Percuss and auscultate both hemithoraces | Asymmetry confirms air in pleural space [3] |
Must-Not-Miss Red Flags – Refer Urgently
- ACS: Prolonged chest pain > 20 min at rest + diaphoresis → call 999 / immediate ECG + troponin [2][4].
- Aortic dissection: Sudden maximal tearing pain to back + inter-arm BP difference → emergency CT aortogram [4][8].
- Massive PE: Pleuritic pain + sudden collapse/syncope + tachycardia + unilateral leg swelling → CTPA [6][8].
- Tension pneumothorax: Absent breath sounds + tracheal deviation + hypotension → needle decompression before CXR.
Top traps that lose marks:
| Trap | How to Avoid |
|---|---|
| Forgetting ICE → lose 3 easy marks | Ask all three explicitly; write patient's own words |
| Listing "chest pain" as the RFC instead of patient's reason | RFC = WHY the patient came TODAY, e.g. fear of heart attack, not the symptom itself |
| Missing aortic dissection in severe sudden pain | Always ask about sudden maximal onset + tearing + back radiation [1][4] |
| Confusing stable angina with ACS | Duration < 10 min + exertional only = stable; rest pain / > 20 min = ACS [2][5] |
| Missing PE – forgetting to ask leg swelling + haemoptysis | Always ask 「有冇隻腳腫？有冇咳血？」 [6] |
| Writing physical sign for IHD as "normal" without offering best available sign | Write "xanthomata" or "S4 gallop" as the best available sign in an FM setting |
| Not giving a safety-net statement at close | Always tell the patient when to come back urgently – scores marks AND is safe practice |
CCTA "Triple Rule-Out" can simultaneously exclude MI, PE, and aortic dissection in borderline cases – high yield for written exam [4].
Shortest safe safety-net line: 「如果你返去之後胸口痛加劇、持續超過20分鐘、透唔到氣、或者暈，要即刻叫白車去急症室。」
High Yield Summary
What to ASK: SOCRATES with specific discriminators (character, radiation, exacerbating factors); red flags (rest pain > 20 min, syncope, haemoptysis, leg swelling, sudden tearing to back); CV risk factors; ICE explicitly.
What to WRITE on CRF: Chief complaint with duration; RFC as the patient's reason, not the symptom; ICE in patient's own words; most likely Dx with ≥ 2 supporting features; 3 DDx each with one discriminator; biopsychosocial (biological problem + psychological worry + social/functional impact); physical sign that matches the most likely Dx.
What NOT to MISS: ACS (rest pain + sweating), aortic dissection (sudden tearing to back), PE (pleuritic + haemoptysis + leg swelling), tension PTX (absent breath sounds). Always safety-net before closing.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: CFB (MED05) Cardiovascular (I) Physical Examination (History Taking).pdf (p15 – SOCRATES comparison table for chest pain causes) [2] Lecture slides: GC 032. Chest pain on exertion_ischaemic heart disease; angina pectoris.pdf [3] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p385–399, atypical features and DDx table) [4] Senior notes: Block A - Sudden severe chest pain_ acute myocardial infarction; aortic dissection.pdf (p1, p6, p33) [5] Senior notes: Block A - WCS32 Chest pain on exertion_ ischaemic heart disease; angina pectoris.pdf (p12, p16) [6] Senior notes: Block A - Leg swelling and chest pain_ deep vein thrombosis; pulmonary embolism; Thrombophilia.pdf [7] Senior notes: Block A - Chest Pain - Department of Medicine.pdf (p1–2) [8] Senior notes: Block A - Chest Pain - Department of Radiology.pdf (p1 – CT aortogram, CTPA)
Headache
Headache is a painful sensation in any region of the head, ranging from sharp to dull, that may arise from primary neurological mechanisms or secondary to an underlying medical condition.
Dizziness / Vertigo
Dizziness is a nonspecific term encompassing sensations of lightheadedness, unsteadiness, or presyncope, while vertigo is the illusory perception of rotational movement of oneself or the environment, typically arising from vestibular system dysfunction.