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Chest Pain-Crash_Course_Internal_Medicine

Chest Pain-Crash_Course_Internal_Medicine

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Published by a_shalby
this is part of Crash.Course Internal.Medicine other parts will publish soon
this is part of Crash.Course Internal.Medicine other parts will publish soon

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Published by: a_shalby on Aug 03, 2009
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1. Chest Pain
Chest pain is a common cause for admission to hospital. Taking a clear history is essential in making the correctdiagnosis. Different diseases present with different types of chest pain.
Differential diagnosis of chest pain
Pleuritic chest pain:
This is a sharp pain that is worse on deep inspiration, coughing, or movement. The differential diagnosis includes thefollowing:
Pulmonary embolus (PE).
Pericarditis: retrosternal.
Bornholm disease (Coxsackie B unilateral infection of respiratory muscles).
Dull central chest pain :
The differential diagnosis of dull central pain includes the following:
Angina: crushing.
Myocardial infarction (MI): crushing.
Dissecting aortic aneurysm: tearing interscapular pain.
Esophagitis: burning.
Esophageal spasm.
Esophageal tear (Boerrhave's syndrome).
Chest wall tenderness :
The differential diagnosis of chest wall tenderness includes the following:
Rib fracture.
Shingles (herpes zoster): pain precedes rash.
Costochondritis (Tietze's syndrome).
Nerve root compression.
Atypical presentations : (or any of the above)
The differential diagnosis in atypical presentations (or in any of the above) includes anxiety and referred pain fromvertebral collapse, causing nerve root irritation or intra-abdominal pathology (e.g., pancreatitis, peptic ulcer, or thebiliary tree). In addition, any of the above diagnoses can present in an atypical manner. For instance, MI can presentas epigastric or jaw pain. For this reason, the most serious causes of chest pain should always be added to thedifferential diagnosis and considered to avoid missing a potentially life-threatening problem.
History in the patient with chest pain :
A careful history of the chest pain will generally be suggestive of the likely underlying problem. It is important duringthe history to take note of any procedures that have been done and what doctors the patient has seen over the pastfew years. In addition, social history (drug use and occupation) and psychiatric history can provide insight into thenature of chest pain (e.g., anxiety disorder, cocaine-induced MI). The focus should then turn to any associatedsymptoms and risk factors.
What type of chest pain does the patient have?Onset and progression of pain
Cardiac ischemic pain typically builds up over a few minutes and may be brought on by exercise, emotion, or coldweather. In angina the pain resolves on resting or with sublingual nitroglycerin (NTG). In unstable angina the pain maycome on at rest and commonly waxes and wanes, becoming severe at times. In MI the pain is severe, often associatedwith systemic symptoms such as nausea, vomiting, and sweating, and lasts for at least 30 minutes. Spontaneouspneumothorax and pulmonary embolism usually causes sudden onset of pleuritic pain (patients often remember exactlywhat they were doing at the time). Pain that follows an episode of vomiting, especially if hematemesis is present,suggests esophageal disease.
Site and radiation of pain
Cardiac ischemia and pericarditis cause retrosternal pain. In ischemia, the pain often radiates to the jaw, neck, orarms, while dissecting aortic aneurysm causes a tearing interscapular pain, and pulmonary disease causes unilateral painwhich the patient can often localize specifically. Esophageal disease can also cause retrosternal pain and may mimiccardiac pain. Referred pain from vertebral collapse or shingles will follow a dermatome pattern.A note about shingles: Lesions never cross the midline except in patients with immunocompromise, which may beiatrogenic (e.g., steroid use) or due to another cause. In addition, the pain of shingles can begin before the rashappears. Patients complain of "electrical" type pain. Treatment with acyclovir is effective only if given within 24 hoursof the initial rash.
Nature of pain
The precise nature of the pain gives important clues as to the underlying diagnosis-for instance, crushing, sharp,pleuritic, burning, or stabbing (see above).
Are there any associated symptoms?Important associated symptoms include:
Dyspnea: pulmonary embolism, pneumonia, pneumothorax, pulmonary edema in cardiac ischemia, hyperventilation inanxiety.
Cough: purulent sputum in pneumonia, hemoptysis in pulmonary embolism, frothy pink sputum in pulmonary edema.
Rigors: pneumonia (particularly lobar pneumonia).Calf swelling: has PE arisen from deep vein thrombosis? Bilateral swelling suggests heart failure.
Palpitations: arrhythmia can cause angina or result from cardiac ischemia, PE, or pneumonia.
Clamminess, nausea, vomiting, and sweating are features of myocardial infarction or massive pulmonary embolism.
Do not forget about anginal equivalents
, such as those listed above, or jaw pain/tightness or indigestion. Anginalequivalents may be the only presenting symptoms of an MI, especially in elderly and diabetic patients. When in doubt,get an ECG and cardiac enzymes.
Are risk factors present?
Important risk factors include:
Ischemic heart disease: smoking, family history, cholesterol, hypertension, diabetes, male sex, age over 50 years.
PE: recent travel, immobility, or surgery, family history, pregnancy, malignancy.
Pneumothorax: spontaneous (young, thin men), trauma, emphysema, asthma, malignancy, staphylococcalpneumonia, cystic fibrosis.
Examining the patient with chest pain :
Vital signs are
and therefore should be checked first. Get in the habit of checking the vital signs yourself toavoid error. The examination should focus on determining the cause of the pain and then looking for risk factors andconsequences of the underlying problem. A schematic guide to examining the patient with chest pain is given in Fig. 1.1. 
What is the cause of the pain?
Pay particular attention to:
Pulse: tachycardia or arrhythmia.
Blood pressure: discrepancy between left and right arms in aortic dissection.
Chest wall tenderness: rib fracture, costochondritis, anxiety, shingles.
Chest examination: pneumothorax, consolidation, pleural rub.
Cardiac examination: fourth heart sound (PE or MI), rub (pericarditis).The following risk factors may be present:
Abnormal lipids: xanthelasma, tendon xanthoma.
Nicotine-stained fingers: predisposition to ischemic heart disease.
Hot, edematous, tender calf, suggesting deep vein thrombosis.
Hypertension: ischemic heart disease.
Also look for signs of venous stasis and arterial insufficiency in the lower extremities. Is there a brown discoloration (hemosiderin staining due to bloodpooling) of the ankles? Does the patient have palpable lower extremity pulses.
What are the complications?
Complications may include:
Pulse: arrhythmia, tachycardia.
Blood pressure: shock in tension pneumothorax, massive pulmonary embolism, MI.
Heart failure: pulmonary edema and 3rd heart sound.
Murmurs: acute mitral regurgitation and ventricular septal defect after MI; aortic regurgitation in dissectingaortic aneurysm.

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