CHEST PAIN - ASSESSMENT - DIFFERENTIALS

Question 1

Chest pain - differentials

Answer 1

• ACS - RED FLAG
  0 Unstable Angina
  0 NSTEMI
  0 STEMI
• Stable Angina
• Pneumonia - RED FLAG
• Viral pleuritis
• GORD
• Costochondritis
• Anxiety or panic disorder.

Question 2

How to differentiate btw the the differientals of Chest pain

Answer 2

ACS -

• Central chest pain
• radiation to Jaw & arm.
• occurs at either rest or on excretion
• may associated nausea & vomiting ( THIS DOES USUALLY HAPPEN IN STABLE ANGINA - !!!!!!!!!)
• may be hypoxic (ischemia leading to infarction) , tachycardic or bradycardic (depending on severity)
  , JVP distension , holosytolic murmur (mitral regurgitation)
  (look at why - heart cannot effectively pump anymore ? - back up of blood )

Stable Angina

• Chest pain on exertion.
• relieved by nitrogylcerine or rest .

*(cardiac biomarkers not elevated , no acute ECG changes - opposite of ACS)

Pneumonia - RED FLAG- (inflammation of the lung by infection) - chest pain (Pleuritic - chest pain on inspiration & associated with SOB)

Associated with myalgias , arthralgias , rigors
, Dullness to percussion (as Pleural effusion may be associated), decreased breath sounds , increased tactile fremitus .

GORD - chest pain (retrosternal usually precipitated by eating , lying flat , relieved by antacids.

Viral pleuritis - associated with cough , nasal congestion , low grade temp , rhinorrhoea.

Anxiety or panic disorder - sharp chest pain associated with trembling , shaking , chills , hot flushes , breathlessness (hyperventilation , sweating , palpitations etc.

Costochondritis

> insidous onset of chest pain & tenderness around 2nd - 5th costochondral joints. (CHEST WALL PAIN - OTHER DIFFERENTIAL LESS LIKLEY TO HAVE THIS - BUT CAN)
— worse on movement or breathing.
RISK FACTORS
- prolonged coughing , repititive upper limb movements causing microtrauma.

LEST COMMON - BUT STILL IMPORTANT

0 Aortic dissection

Acute substernal tearing sensation , may radiate to intrascapular region of back .
(AA can cause ——————-> Cardiac tamponade , MI , Aortic regurgitation)

• can pulse deficit & hypoperfusion - extremities cold , blue , clammy.

0 Aortic stenosis - RED FLAG- typical angina, SOB , syncope (if severe)

0 Pneumothorax - RED FLAG (collasped lung)- pleuritic chest pain, SOB etc.

0 Peptic ulcer disease - Epigastric pain.

0 Oesophageal spasm
(Crushing substernal chest pain , pain not only associated with swallowing. )

• Acute cholecystitis - radiation to intrascpaular area from RUQ.
  ( & Nausea & vomiting)

Acute pancreatitis - radiation to back from epigastric or periumblical andomainal pain.
( & Nausea & Vomiting , Hx of alcohol consumption)

Question 3

What is Costochondritis ?

Answer 3

Costochondritis - inflammation where ribs meet breast bone (sternum) - inflamm of costal cartilages.

*usually self limiting

SIGNS & SYMPTOMS

0 Insidious onset of chest pain & tenderness around 2nd - 5th costochondral joints.

• Pain worse on movement or breathing.

RISK FACTORS
0 prolonged coughing ,
0 repetitive upper limb movements causing microtrauma.

Question 4

Treatment of Costochondritis ?

Answer 4

Inflammatory causes

1ST LINE

NSAIDS (pain relief )
if concomitant history of GI bleed , >60 years , use of steriod or anticoagulants ——————> GIVE COX-2 inhibitor e.g. celecoxib vs non -selective NSAID + PPI considered.

2ND LNE

Intra - articular injection with corticosteriod plus local anasthetic (Lidocaine)
(IF NSAID UNSUITABLE /NOT WORKING)

Infective

1ST LINE

0 Surgical drainage and.or debridement + Antibiotics.

Question 5

What is Tietze’s syndrome ?

Answer 5

Inflammation of the costochrondral joints with OVERLYING SWELLING

• SIMILAR TO COSTOCHONDRITIS (but has Tietze has overlying swelling )
• ALSO MOSTLY AFFECTS 2ND - 3RD RIB VS COSTOCHONDRITIS (2ND TO 5TH)

Pain can go away but swelling may persist long after.

Question 6

Diagnosis of Costochondritis ?

Answer 6

Clinical diagnosis

NSAID drug trial - if there is strong clinical suspicsion
(if NSAID not possible - Local anasthetic (LIDOCAINE ) + Steriod trial )

CONSIDER -

CXR - if not clear to rule out differentials.
(if present - may see chrondral enlargement )

same for CT chest , MRI Chest

wound & blood cultures if infective cause.

Question 7

What are the urgent considersations of chest pain?

Answer 7

0 ACS

0 Aortic dissection

0 Tension pneumothorax

0 Pulmonary embolism

0 Cardiac tamponade.

• CAN GO INTO SHOCK .