DOORWAY-CHEST PAIN Flashcards
CHEST PAIN-DIFFERENTIALS
Heart
- Covering: Pericarditis,
- Muscle: CardiomyopathyX
- Vessels: IHD/MI, Aortic Dissection, Cocaine Abuse (vessel spasm)
(IHD=ISCHEMIC HEART DISEASE)
ACUTE CORONARY SYNDROME (INCLUDES MI, BOTH ANGINA)
Lung
- Covering: Peuritis
- Parenchyma: Pneumonia
- Vessel: Pulmonary Embolism
-Pneumothorax
Rib contusion
Esophagus
- GERD
- Esophageal spasm
PUD
Skin
- Costochondritis
Muscle
Muscle strain
Other
Cocaine abuse
Sickle cell disease acute chest syndrome
RULE OUT PERICARDITIS- (INFLAMMATION OF LINING OF THE HEART)
For Pericarditis: (pain related to position)
a. Have you recently suffered from flu (runny nose, watery eyes, sore throat, fever, fatigue)?
Have you had any recent infections?
Do u have rash? (Pericarditis caused by coxsackie virus)
OTHER THINGS TO KNOW:
Chest pain: often sharp, pleuritic; improves on sitting and leaning forward, retrosternal stabbing chest pain. worsens with deep inspiration.
Low-grade intermittent fever, tachypnea, dyspnea, nonproductive cough (flu like symptoms are seen)
most commonly caused by infection or myocardial infarction, or occurs following cardiac surgery.
PERICARDITIS WORKUP
The diagnosis is based primarily on a history of pleuritic chest pain and a friction rub heard on auscultation. It is supported by the following findings:
Blood tests: CBC (leukocytosis), ↑ troponin I, ↑ ESR, ↑ CRP, abnormal renal parameters (BUN, creatinine, electrolytes) if caused by underlying uremia
Typical ECG changes: not present in uremic pericarditis
Stage 1: initial diffuse ST elevations, but ST depression in aVR and V1; PR segment depression
Stage 2: ST segment normalizes in ∼ 1 week.
Stage 3: inverted T waves
Stage 4: ECG returns to normal baseline (as prior to onset of pericarditis) after weeks to months.
Echocardiography: often normal; possibly signs of effusion
Chest x-ray normal
RULE OUT MYOCARDIAL INFARCTION-BLOOD SUPPLY TO THE HEART IS DISTURBED
For MI:
a. Have you noticed any Shortness of breath?
b. Is the pain associated with sweating? Any nausea? Racing of heart?
c. Has the pain improved after resting?
OTHER
Sudden onset of substernal heavy/crushing/squeezing chest pain, radiates to left arm
Accompanied by dyspnea, diaphoresis, and nausea
History of HT, hyperlipidemia, and smoking
MYOCARDIAL INFARCTION WORKUP
ECG-BEST INITIAL
CPK-MB, troponin x 3 Troponin T is the most important cardiac-specific marker and may be measured 3–4 hours after the onset of myocardial infarction. CK-MB values correlate with the size of the infarct, reach a maximum after approximately 12–24 h, and normalize after only 2–3 days, making CK-MB a good marker for evaluating reinfarction.
CXR
CBC
Helical CT to visualize the coronary arteries
RULE OUT AORTIC DISSECTION-THE TISSUE OF THE BV HAS THREE LAYERS AND ONE OF THEM GETS INJURED AND OPENS UP SO THE BLOOD SORT OF ACCUMULATES BETWEEN THE LAYERS
Did you experience any loss of consciousness(passes out)?
OTHER
sudden onset of severe chest
pain that radiates to his back.
History of uncontrolled hypertension.
syncope
diaphoresis
can radiate to neck and jaw
AORTIC DISSECTION WORKUP
Initial imaging: Chest x-ray (AP view) showing a widened mediastinum (> 8 mm)
A transthoracic echocardiogram (TTE) is the most common noninvasive type of echocardiogram, which uses high frequency soundwaves (ultrasound) to create a moving picture of your heart through the chest wall. moving image of the internal parts of the heart using ultrasound.
Definitive diagnostic tests (determine the type of lumen, location, and extent of the dissecting membrane)
In stable patients → Contrast-enhanced CT angiography (gold standard) High sensitivity and specificity.
In unstable patients, renal insufficiency, contrast allergy → Transesophageal echocardiography (TEE)
If contrast-enhanced CT is contraindicated in stable patients → Magnetic resonance angiography (MRA)
ECG: in all patients, although normal or signs of left ventricular hypertrophy
CPK-MB, troponin
CBC
RULE OUT COCAINE ABUSE-VASOSPASM (VESSEL GETS BIGGER AND SMALLER)
Do you have any nose bleeds or redness of the nose?
Clinical features
Snorting can cause damage to the nasal vessels and result in nosebleeds
Intoxication
Nausea, sweating, unstable heart rate and blood pressure (may be increased or decreased), chest pain, mydriasis, chills, euphoria
Respiratory depression, tachyarrhythmia , malignant hyperthermia, paranoid symptoms with tactile, acoustic, and optic hallucinations, ataxia
Withdrawal
Marked psychological dependence even after first exposure characterized by a strong desire to use cocaine
Physiologic “crash”: lack of energy, depression, constricted pupils, psychomotor agitation, vivid dreams, increased appetite
COCAINE ABUSE WORKUP
URINE TOXICOLOGY
ECG
CPK-MB, TROPONINS
CBC, ESR
RULE OF PLEURITIS-INFLAMMATION OF THE TISSUE THAT LINES THE LUNGS
Pleuritis (Pleurisy)
Sharp chest pain that is worse with inhalation. Caused by inflammation of the pleura that lines the lungs. Most commonly due to viral infection, but can also occur in pneumonia, lung cancer, or pulmonary embolism.
RULE OUT PNEUMONIA-LUNGS GET INFLAMMANED AFTER AN INFECTION
For Pneumonia:
a. Have you ever been exposed to anybody with similar complaints? OR Is anybody around you also sick?
b. Have you suffered from a cough recently?
OTHER
Typical pneumonia presents with as sudden onset of symptoms caused by lobar infiltration.
Severe malaise
High fever and chills
Productive cough with purulent sputum (yellow-greenish)
Crackles, bronchial, and decreased breath sounds on auscultation
Enhanced bronchophony, egophony, and tactile fremitus
Dullness on percussion
Tachypnea and dyspnea (nasal flaring, thoracic retractions)
Pleuritic chest pain when breathing, often accompanying pleural effusion
Pain projecting to the abdomen and epigastric region (particularly in children)
Atypical pneumonia is commonly seen in elderly patients and typically takes an indolent course (slow onset) with an emphasis on extrapulmonary symptoms.
Low fever, no chills
Non-productive, dry cough
Dyspnea
Extrapulmonary features
Fatigue, headaches, sore throat, myalgias
Erythema multiforme with Mycoplasma pneumonia
Auscultation often unremarkable
PNEUMONIA WORKUP
CHEST XRAY
CBC
SPUTUM AND BLOOD CULTURES
RULE OUT PULMONARY EMBOLISM-PROLONGED SITTING OR INACTIVITY CAN CAUSE THE BLOOD TO CLOT AND THAT CLOT CAN MOVE
a. Have you noticed calf pain or swelling?
b. Have you been immobilized (OR TRAVELING) recently?
c. Are you using Oral Contraceptive Pills (BIRTH CONTROL PILLS) recently?
OTHER
Acute onset of symptoms, often triggered by a specific event (e.g., on rising in the morning, sudden physical strain/exercise)
Dyspnea and tachypnea (> 50% of cases)
Sudden chest pain (∼ 50% of cases), worse with inspiration
Cough and hemoptysis
Possibly decreased breath sounds, dullness on percussion, split-second heart sound audible in some cases
Chest wall tenderness on palpation
Tachycardia (∼ 25% of cases), hypotension
Jugular venous distension
Low-grade fever
Syncope and shock with circulatory collapse in massive PE
Symptoms of DVT: unilaterally painful leg swelling
PULMONARY EMBOLISM WORKUP
o~dimer
CTA-chest with IV
contrast
CXR
RULE OUT PNEUMOTHORAX-CAUSE BY INJURY WHICH RESULTS IN AIR ENTERING THE LUNGS
Have you had any injury recently?
OTHER
Spontaneous pneumothoraxPrimary (idiopathic or simple pneumothorax)
Ruptured subpleural apical blebs
Risk factors
Family history
Male gender
Asthenic body habitus (slim, tall stature) (e.g., in Marfan syndrome)
Smoking: 90% of cases; up to 20-fold increase in risk (risk increases with cumulative amount of cigarettes consumed)
Homocystinuria
Secondary (pneumothorax as a complication of underlying lung disease)
Catamenial pneumothorax (extremely rare; thoracic endometriosis)
Pulmonary tuberculosis
Cystic fibrosis → bronchiectasis with obstructive emphysema
Pneumocystis pneumonia → alveolitis, rupture of a cavity
COPD (smoking) → rupture of bullae in emphysema
Traumatic pneumothorax: blunt (e.g., motor vehicle accident with impact of thorax onto the steering wheel or rib fracture) or penetrating (e.g., gunshot) injury
Traumatic pneumothorax: This patient suffered a blunt trauma to the chest when he fell off his bike and is now experiencing stabbing chest pain and shortness of breath. In conjunction with an increased respiratory rate, mild tachycardia, pain on inspiration, decreased breath sounds on the left, and decreased vocal fremitus, this history is consistent with a pneumothorax.
Iatrogenic pneumothorax: Mechanical ventilation (Mechanical ventilation with high PEEP may result in barotrauma), thoracocentesis, central venous catheter placement, or bronchoscopy
PNEUMOTHORAX WORKUP
CHEST XRAY
CBC
RULE OUT RIB CONTUSION-INJURY AROUND THE RIB CAN CAUSE CHEST PAIN WITHOUT RIB GETTING FRACTURED
Have you been in any type of accident or had any injury?
OTHER
Rib contusion: This patient’s history of blunt chest trauma followed by chest pain that worsens on inspiration and tenderness to palpation over the left side of the chest suggests a rib contusion or rib fracture. Given the absence of crepitus or a visible fracture line on chest x-ray, rib contusion is most likely here. Subtle rib fractures can be overlooked on a normal chest x-ray and can sometimes only be diagnosed with a rib series x-ray or CT.
RULE OUT GERD-When the contents of the stomach flow backwards.
For GERD:
a. Have you noticed any burning sensation in your chest or change in taste of your mouth?
b. Have you noticed any changes in your voice? (hoarseness)
OTHER
Risk factors/associations
Lifestyle habits such as smoking, caffeine and alcohol consumption
Stress
Obesity
Pregnancy
Clinical
Chief complaint: retrosternal burning pain (heartburn) that worsens while lying down (e.g., at night) and after eating
Pressure sensation in the chest
Belching, regurgitation
Dysphagia
Chronic non-productive cough and nocturnal cough
Nausea and vomiting
Halitosis
Triggers:
Bending down, supine position
Habits: smoking and/or alcohol consumption
Psychological factors: especially stress
GERD WORKUP
ECG
Barium swallow
Upper endoscopy
Esophageal pH
monitoring
H pylori stool antigen
RULE OUT ESOPHAGEAL SPASM-
Progressive dyphagia
Regurgitation of undigested food/saliva
Weight loss
Dysphagia
Retrosternal chest pain Squeezing type, occurs with eating
Regurgitation
ESOPHAGEAL SPASM
Esophagogram
Esophageal manometry
RULE OUT COSTOCHONDRITIS-INFLAMMATION OF THE RIB CAGE
When he/she shows you the location, ask him if it hurts when he touches the spot.
Does it hurt when you touch it?
OTHER
May have a history of recent exercise/exertion/chest wall trauma
Sharp, well-localized pain
Pain reproducible with palpation
RULE OUT MUSCLE STRAIN-
Did you have any injury recently?
OTHER
Definition: excessive stretching of a muscle, which can lead to a tear
Etiology
Longitudinal stretching of the muscle to a point beyond the elastic limit during active contraction
The musculotendinous junction is the most common site of injury.
RULE OUT SICKLE CELL DISEASE ACUTE CHEST SYNDROME
OTHER
LOOK IN HISTORY
sickle cell disease and multiple hospitalizations for
pain and anemia management.
