Approach to Chest Pain
Pulmonary Embolism • Pneumothorax • Acute Coronary Syndrome • MRCP (UK) PACES
A structured MRCP (UK) PACES approach to a patient presenting with chest pain. Learn how to distinguish life-threatening causes, prioritise immediate investigations and communicate a clear management plan using a systematic clinical framework.
At a Glance
Red Flags
Immediate Priorities
PACES Approach
Chest Pain Diagnostic Framework
ACS
Pericarditis
Aortic Dissection
Pulmonary Embolism
Pneumothorax
Pneumonia
Pleurisy
Costochondritis
Muscle Strain
Rib Fracture
GORD
Oesophageal Spasm
Peptic Disease
Herpes Zoster
Anxiety
Functional Pain
ACS
PE
Pneumothorax
Aortic Dissection
Overview
Chest pain is one of the most common and important presenting complaints in MRCP (UK) PACES. Candidates should rapidly identify life-threatening conditions such as acute coronary syndrome, pulmonary embolism, pneumothorax and aortic dissection before considering other causes including pericarditis, pneumonia, gastro-oesophageal reflux disease and musculoskeletal chest pain. A systematic history, focused examination and appropriate investigations allow safe prioritisation of diagnosis and management. The scenario in this resource particularly highlights the need to consider pneumothorax and pulmonary embolism in a hospitalised patient with PCP pneumonia who develops sudden pleuritic chest pain and hypoxia. :contentReference[oaicite:0]{index=0}
Structured History
- Time of onset and progression of chest pain
- Site, radiation and severity of pain
- Nature of pain (sharp, crushing, burning or tearing)
- Pleuritic pain (worse on deep inspiration or coughing)
- Relationship to exertion, posture or meals
- Associated symptoms: breathlessness, palpitations, sweating, nausea or syncope
- Cough, fever, sputum or haemoptysis
- Risk factors for venous thromboembolism (recent surgery, immobility, malignancy, pregnancy)
- Past history of ischaemic heart disease, pneumothorax or thromboembolism
- Drug history, smoking history and cardiovascular risk factors
Examination
- General appearance and level of distress
- Pulse, blood pressure, respiratory rate, temperature and oxygen saturation
- Inspect for cyanosis or respiratory distress
- Examine the chest for asymmetry, reduced expansion and tracheal deviation
- Percuss for hyper-resonance or dullness
- Auscultate for reduced breath sounds, crackles or pleural rub
- Cardiovascular examination including heart sounds and pericardial rub
- Palpate the chest wall for tenderness
- Examine the calves for swelling or tenderness
- Assess for signs of shock or haemodynamic instability
Differential Diagnosis
Investigations
- 12-lead ECG
- Chest X-ray
- Arterial Blood Gas if hypoxic
- High-sensitivity Troponin
- Full Blood Count, U&E and CRP
- D-dimer (when appropriate)
- CT Pulmonary Angiography if pulmonary embolism is suspected
- Lower limb Doppler ultrasound if DVT is suspected
- Echocardiography when pericardial disease or cardiac dysfunction is suspected
- CT Aortogram if aortic dissection is suspected
Diagnosis
Acute Chest Pain – Determine the Underlying Cause
The diagnosis is based on careful clinical assessment supported by targeted investigations. In PACES, the priority is to rapidly identify or exclude immediately life-threatening conditions such as acute coronary syndrome, pulmonary embolism, pneumothorax and aortic dissection before considering less urgent causes.
Management
Explaining to the Patient
"Chest pain can have many different causes. Some are minor, while others require urgent treatment. Our immediate priority is to identify or exclude serious conditions affecting the heart, lungs or major blood vessels. We will perform an ECG, blood tests and a chest X-ray, and if needed arrange further scans to determine the exact cause before starting the most appropriate treatment."
Examiner's Corner
What are the life-threatening causes of chest pain?
How do you differentiate pleuritic chest pain?
- Pulmonary embolism – sudden pleuritic pain with dyspnoea and risk factors for venous thromboembolism.
- Pneumothorax – sudden unilateral pleuritic pain with reduced breath sounds and hyper-resonance.
- Pneumonia/Pleurisy – fever, cough and focal chest signs.
- Pericarditis – pain relieved by sitting forward and worsened by lying flat.
- Musculoskeletal pain – reproducible with palpation or movement.
Common Viva Questions
- How do you approach a patient with acute chest pain?
- Which diagnoses must be excluded first?
- When should CT pulmonary angiography be requested?
- How do you diagnose a pneumothorax clinically?
- When is D-dimer appropriate?
- What ECG findings suggest pericarditis?
- How would you explain your differential diagnosis to the examiner?
Initial Emergency Management
- ABCDE assessment
- Continuous monitoring and intravenous access
- 12-lead ECG within 10 minutes
- Supplemental oxygen if hypoxic
- Analgesia as appropriate
- Treat the underlying cause without delay
Pathfinder Pearls
Common Pitfalls
- Anchoring on a single diagnosis too early.
- Missing pulmonary embolism in a patient with pleuritic chest pain.
- Failing to recognise a pneumothorax clinically before imaging.
- Overlooking acute coronary syndrome despite atypical symptoms.
- Ignoring abnormal vital signs or hypoxia.
- Using D-dimer in patients with a high clinical probability of pulmonary embolism.
- Delaying urgent senior review in an unstable patient.
Master MRCP (UK) PACES with PACES Pathfinders
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