Thursday 7th November 1991   Morning coffee break 12:00

Dr Lewis gave each of us our coffee and sat down.
“Right, I would like to discuss 3 different types of chest pain whilst we are having coffee this morning. You can start, Dylan. How would you describe cardiac pain?”
“Well . . . it is usually in the middle of the chest or on the left side. The pain can radiate into the left arm or up into the throat or jaw. Sometimes, it goes through to the back. Most patients describe it as a severe, aching pain. It can feel like pressure or a heavy weight on the chest.”
“Good! Is there anything that brings it on or makes it worse?” Dr Lewis asked.
“Exercise: walking, especially uphill or in a cold wind.”
“Excellent, Dylan. Do you know of any associated features?”
“Breathlessness, sweating . . .”
“Dizziness as well,” said Dilys.
Dylan frowned. “I know that, Dilys. I was just going to tell Dr Lewis before you interrupted.”
Dr Lewis shook her head and looked at them both. “I have had enough of this bickering. I would like you to try to work as a team. Help each other!”

“Dilys, it’s your turn,” Dr Lewis continued. “Pain due to indigestion can be very similar to cardiac pain. I would like you to tell me some of the differences.”
“I suppose that indigestion occurs lower down, in the epigastric area.” Dilys glanced at Dylan and spoke quickly. “It can radiate through to the back as well. Food often affects the pain. It can make it worse or help sometimes . . .  some patients with ulcers get hunger pains . . .  I nearly forgot that.  Indigestion is not normally affected by exercise. It may be associated with nausea or burping.” Dilys paused briefly and took a breath. “If the patient has a hiatus hernia, they may get a lot of heartburn or acid reflux. I don’t think indigestion pain is usually as severe as heart pain.”
“Of course not!” said Dylan.
Dr Lewis raised her eyebrows. “Actually, it can be very difficult to distinguish between the two,” she said. “You have to make sure that patients don’t try to catch you out. I think Mr Jones, our first patient this morning, was playing his symptoms down. His pain sounded very typical of angina to me.”
“I thought that,” said Dilys.
“Jenny Derbyshire, on the other hand, was very dramatic.” Dr Lewis continued. “She insisted that she was having a heart attack even though the pain sounded exactly like her normal oesophageal spasm. She gets it every time her hiatus hernia flares up.”
“She didn’t look too pleased when you suggested Gaviscon,” said Dilys.
“It always seems to help.”

“Right, Dennis, do you want to tell us about pleuritic pain?” Dr Lewis turned towards me.
“Pleuritic pain is sharp. It’s like a knife. It hurts when the patient breathes in.”
“Yes . . . A lot of patients say that the pain catches their breath.”
“Ross Conwy said it was just like his broken rib.” I continued. “We saw him with Dad last week.”
“The pain can be very similar. Pleuritic pain is usually affected more by breathing than moving whereas the pain due to a broken rib can be affected as much by both.”
“It is usually on one side rather than in the front,” I added, “and patients may feel out of breath with it.”
“Good.” Dr Lewis smiled.
“A patient with pleuritic pain might have the symptoms and signs of a chest infection,” Dilys added.
“Yes,” said Dr Lewis. “A chest infection is one of the commonest causes of pleurisy.”
“It could be caused by a clot,” added Dylan.
“Quite right, Dylan. As we all know, it is very important not to miss a clot.”
“What about lung cancer?” asked Dilys.
“Yes, lung cancer can cause pleuritic pain,” said Dr Lewis. “That’s something else we don’t want to miss.”

“There you are. There are 3 common types of chest pain for you to think about; cardiac pain, pain due to indigestion and pleuritic pain. I would like you to look them up tonight to reinforce your knowledge. I may test you tomorrow.”

Chest pain 3 ways.