Differential Diagnosis of Chest Pain Flashcards
Somatic (body wall structure) sources if central chest pain
Muscle
Joint
Bony
Intervertebral disc
(Fibrous) pericardium
Nerve (e.g.intercostal)
Visceral (organ) sources of central chest pain
Heart and great & vessels
Trachea
Oesophagus
Abdominal viscerae
What tends to be the nature of somatic pain?
Typically sharp, stabbing, well localised
What tend to be the nature of visceral pain?
Typically dull, aching, nauseating, poorly localised
What is radiating pain?
Pain felt in the center of the chest (actual site of pathology) AND felt radiating from there
> upper limbs
> back
> neck
What is referred pain?
Sensation of pain felt ONLY at site remote from the actual area of injury or disease e.g damage at heart but felt in:
> upper limbs
> back
> neck
>NOT felt centrally in chest
This is due to afferent (sensory) fibres from SOMA and afferent (sensory) fibres from viscera (visceral afferents) entering the spinal chord at the same levels
Brain chooses to believe that the pain signals coming from the organ (heart), are actually coming from the soma (upper limbs, especially in left upper limb or from back,neck,jaw)
What happens when you prod someone in the dermatone T5 region on their RHS
APs travel along anterior ramus of spinal nerve T5
Will then pass into spinal nerve
Will then pass through dorsal root ganglion and into dorsal root
Into dorsal rootlets
Then synapsing in T5 spinal chord segment
The pain pathway will cross spinal chord to opposite side (LHS)
Next neurones in chain will pass up LHS of spinal chord and sensation will come into consciousness of cerebral cortex
Why is the central sulcus important?
In differentiating motor and sensory information
What does the postcentral gyrus part of the parietal lobe do? (Position just behind the central sulcus)
It is somatosensory: APs arriving here bring body wall (somatic) sensations into “consciousness”
What does the precentral gyrus part of the frontal lobe do? (Position just before the central sulcus)
Somatomotor: APs originating here bring about contractions of body wall (somatic) skeletal muscle
“Sharp” somatic central chest pain - herpes zoster “shingles”
Reactivation of dormant virus in posterior rot ganglion
Pain can be felt anywhere in dermatome
Pain precedes blisters
Patients with shingles developing inT4/5 dermatome may Present with central chest pain
“Sharp” somatic central chest pain - muscle,joint & bone
Pectoral is major or intercostal muscle strain
Dislocated costochondral joint
Costovertebral joint inflammation
“Slipped” thoracic intervertebral disc
All can be felt as central chest pain
“Sharp” somatic central chest pain - parietal pleura & fibrous pericardium
Pleurisy
Pericarditis
“Dull” visceral central chest pain sources
Trachea - tracheitis
Aorta - ruptured aneurysm of aortic arch
Abdominal viscerae - gastritis, cholecystitis, pancreatitis, hepatitis etc
Heart - angina & myocardial infarction
Oesophagus - oesophagitis
Why can the brain be confused as to where chest pain is coming from?
Somatic sensory fibres from body wall also enter spinal chord at relevant spinal nerve level
Both somatic sensory fibres from body wall AND visceral afferents from organs enter the spinal chord at same levels
The heart will enter at thoracic and lower cervical levels and the body wall will also be entering at these thoracic levels
Somatic sensory and visceral fibres entering spinal chord at the same level - confuses brain
