Differentials Flashcards
Where can chest pain radiate?
Epigastrium
Arm
Neck
Jaw
What is the character of pneumothorax chest pain?
Sudden onset pleuritic pain either left or right-sided with associated dyspnoea and syncope. Often young males.
What is the character of musculoskeletal chest pain?
Pain typically persistent (typically days or longer), worsened with passive and active motion and sometimes reproducible chest tenderness.
What is the character of angina chest pain?
Exertional pain/discomfort in the centre or left side of the chest, throat, neck or jaw is relieved by rest or GTN within a few minutes. May radiate to the neck, jaw or left arm. Sometimes there may not be any pain but breathlessness.
What is the character of pericarditis chest pain?
Constant or intermittent central pleuritic sharp pain often aggravated by position (classically worse on lying down and relived by sitting or leaning forward).
What is the character of peptic ulcer disease pain?
Recurrent, vague epigastric discomfort, that is relieved by food, anatacids or both.
What is the character of pulmonary embolism chest pain?
Sudden onset pleuritic chest pain with associated dyspnoea and tachycardia. Sometimes mild fever, syncope and haemoptysis.
What is the symptoms of ACS?
- Acute, crushing pain radiating to the jaw or arm
- Exertional pain relieved by rest
What are the clinical signs of ACS?
- Sinus tachycardia
- Xanthelasma
- Tar staining on fingers
- New murmur (mitral regurgitation - pan-systolic)
What are the symptoms of aortic dissection?
- Sudden, tearing pain radiating to the back
- Some patients have syncope, stroke or leg ischaemia
- PMH of HTN and/or FHx of connective tissue disease e.g. Marfan syndrome
What are the clinical signs of aortic dissection?
- Pulsus paradoxus (BP falls on inspiration)
- Difference in BP in both arms
- Distended neck veins
- Muffled heart sounds
- Radio-radial delay
What are the symptoms of myocarditis?
- Fever
- Dyspnoea
- Fatigue
- Chest pain (if myopericarditis)
- May be pleuritic
- Recent viral or other infection
- Fever
- Tachycardia
What are the clinical signs of pericarditis?
- Tachycardia
- Pericardial rub
- Recent viral infection
What are the risk factors for a pulmonary embolism?
- Tachycardia
- Red, swollen, painful leg
- Immobile for a long period
- Inherited conditions such as blood clotting disorders
- Recent surgery or bone fracture
- History of cancer or receiving chemotherapy
- Acute medical illness e.g., DKA, sepsis
What are the clinical signs of pneumothorax?
- Hypotension
- Neck vein distension
- Tracheal deviation
- Unilateral diminished breath sounds
- Hyperresonance to percussion
What are the symptoms of pneumonia?
- Pleuritic chest pain
- Fever
- Productive cough
- Purulent sputum - green/blood stained
What are the clinical signs of pneumonia?
- Reduced air entry
- Bronchial breathing
- Crepitations
- Immunosuppression or elderly
What are the symptoms of pancreatitis/gallstones/hepatitis?
- Pain in the epigastrium or lower chest that is often worse when lying flat and is relived by leaning forward
- Vomiting
- Upper abdominal tenderness
What is the pain character in GORD?
Recurrent burning pain radiating from epigastrium to throat, exacerbated by bending down or lying down and relieved by antacids.
What are the symptoms of shingles?
- Sharp, band-like pain in the thorax unilaterally
- Classic linear, vesicular rash
- Pain may precede rash by several days
- Rash on chest with vesicles - dermatomal distribution
- Pain made worse by contact with clothing
What is the Stanford classification for aortic dissection?
Type A - involves ascending aorta
Type B - does not involve ascending aorta
What is the underlying pathology of aortic dissection?
- Atherosclerosis
- HTN
- Aortic aneurysm
- Bicuspid aortic valve
- Connective tissue disease
- Marfan’s syndrome
What can be seen on a CXR for aortic dissection?
False lumen - this enlarges and occludes the true lumen, potentially compromising the blood supply of organs distal to dissection tear.
Describe unstable angina
Patients present with ischaemic symptoms with no elevation in troponins, often treated as NSTEMI due to troponin rise occurring later.
What are the symptoms of ACS?
- Chest pain, typically central/left-sided
- May radiate to the jaw or left arm
- Certain patients e.g., diabetics/elderly may not experience any chest pain
- Dyspnoea
- Sweating, n+v
What are the clinical signs of ACS?
- Very few physical signs
- Potentially tachycardia
- Pale and clammy
- If complications of ACS then those signs may show
What are the shockable heart rhythms?
- Ventricular fibrillation
- Pulseless ventricular tachycardia
What are the non-shockable heart rhythms?
- Asystole
- Pulseless electrical activity (PEA)
What are the different types of AF?
- Recurrent episodes, when a patient has 2 or more episodes of AF
- If episodes of AF terminate spontaneously then the term paroxysmal AF is used - last less than 7 days (<24 hrs)
- If the arrhythmia is not self-terminating then it is persistent AF, this lasts >7 days
- Permanent AF is continuous and cannot be cardioverted or if attempts to do so are deemed inappropriate
What are the symptoms of AF?
- Palpitations
- Dyspnoea
- Chest pain
What are the common causes of AF?
SMITH
- Sepsis
- Mitral valve pathology (stenosis or regurgitation)
- Ischaemic heart disease
- Thyrotoxicosis
- Hypertension
- Lifestyle - alcohol and caffeine
What are the features for coarctation of aorta?
- Infancy: heart failure
- Adult: hypertension
- Radio-femoral delay
- Mid systolic murmur, maximal over the back
- Apical click from the aortic valve
notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children
What are the features of pericarditis?
- Fever or recent viral illness
- Recent MI (associated with Dressler’s syndrome)
- PMH of RA, SLE, sarcoid or radiotherapy
What are other features of peptic ulcer?
- Associated symptoms include dysphagia, acid reflux, weight loss and melaena
- Drug history includes NSAIDs, steroids or any others
- Can have retrosternal radiation
What are the common features associated with AF?
- Elderly patient
- PMH of IHD, CCF, mitral valve disease
- Recent onset coinciding with symptoms suggestive of LRTI
What are the common features associated with SVT?
- PMH of COPD (predisposes to multifocal atrial tachycardia)
- Associated with symptoms of compromise e.g. chest pain, SOB, pre-syncope
- Previous episodes terminated by vagal manoeuvres e.g. blowing the nose
What are the common features associated with VT?
- Symptoms of compromise e.g. chest pain, SOB, pre-syncope, cold peripheries, sweating
- Hx of recent MI
- PMH of IHD
- FH of sudden death, known long QT syndrome
What are the common features associated with thyrotoxicosis?
- Sinus tachycardia or AF
- PMH of thyroid disease
- PMH of other autoimmune disease (insulin-dependent diabetes, vitiligo, Addison’s, pernicious anaemia etc)
What are the symptoms of thyrotoxicosis?
- Weight loss
- Increased appetite
- Heat intolerance
- Diarrhoea
- Tremor
- Mood disturbance
What are the common features associated with HOCM?
- FH of sudden death or HOCM
- Collapse while playing sport
What are the common features associated with phaeochromocytoma?
- Triad of episodic headache, sweating, fast palpitations
- Weight loss
- Symptoms of anxiety
What are the common features associated with simple anxiety or GAD?
- Associated with important/stressful event
- No symptoms of compromise or hx of cardiac/thyroid disease
- PMH of depression
- Avoidance of predisposing situations (GAD)
What are the common features associated with ventricular ectopics?
- Recent MI
- PMH of IHD
- Description of missed beat followed by heavier beat
What are the common features associated with hypoglycaemia?
- Associated with sweating, anxiety, hunger, tremor, dizziness
- PMH of diabetes
- DH of hypoglycaemic medication (not metformin)
- Hx of liver disease, Addison’s disease
