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Chest Pain - Differencial Diognosis

Chest Pain - Differencial Diognosis

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Published by: g3murtulu on Feb 05, 2010
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08/15/2010

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Disorders that affectthoracicor abdominal organs
— the heart, pleurae, lungs, esophagus, rib cage,gallbladder, pancreas, or stomach — are typical causes of chest pain. It can also result from a musculoskeletal or hematologic disorder, anxiety, and drug therapy. Chest pain is an important indicator of several acute and life-threatening cardiopulmonary and GI disorders.The onset of chest pain can be sudden or gradual, and its cause may initially be difficult to ascertain. Chest pain canradiate to the arms, neck, jaw, or back. It can be steady or intermittent, mild or acute. And it can range in character froma sharp shooting sensation to a feeling of heaviness, fullness, or even indigestion. Chest pain can be provoked or aggravated by stress, anxiety, exertion, deep breathing, or eating certain foods.
Act Now
:
Sudden, severe chest pain requires prompt evaluation and treatment because it may herald a life-threatening disorder. (See Managing severe chest pain, pages 76 and 77.) Standardized algorithms are used toaddress the treatment regimen of the patient with chest pain. Determine the time of onset and whether it wassudden or gradual. Ask the patient about precipitating, alleviating, or aggravating factors, if the pain radiates,and associated signs and symptoms. Ask him to rate the pain using a standardized pain rating scale. Obtain a12-lead electrocardiogram (ECG) and a blood sample for serum testing. Administer oxygen through a nasalcannula. Place the patient on a cardiac monitor and establish I.V. access. If test results indicate an acutemyocardial infarction (MI), the patient will require emergency percutaneous coronary intervention or fibrinolytic therapy. Be prepared to administer emergency care if the patient experiences cardiopulmonaryarrest.
Differential Diagnosis of Chest PainCardiovascular
1.
Typical angina pectoris
2.
Prinzmetal’s or variant angina
3.
Unstable or accelerating angina
4.
Acute myocardial infarction
5.
Aortic dissection
6.
Mitral valve prolapse
7.
Pericarditis
8.
Dressler’s syndrome
9.
Postpericardiotomy syndrome1
 
Pulmonary
1.
Pleuritic chest pain
2.
Pneumonia
3.
Pulmonary embolism
4.
Pulmonary hypertension
5.
Spontaneous pneumothorax
Gastrointestinal
1.
Reflux esophagitis
2.
Esophageal spasm/angina
3.
Peptic ulcer 
4.
Pancreatitis
5.
Cholecystitis
Musculoskeletal disorders
1.
Costochondritis
2.
Tietze’s syndrome
3.
Rib fracture or trauma
4.
Cancer metastsis
5.
Sternoclavicular arthritis
6.
Painful xiphoid syndrome
7.
Fibromyalgia
8.
Traumatic muscle pain
9.
Shoulder arthritis/bursitis
10.
Cervicothoracic nerve root compression
11.
Thoracic spine arthritis
12.
Throracic outlet syndrome
Miscellaneous
1.
Herpes zoster 
2.
Anxiety/depressive disorder 
3.
Panic disorder 
4.
Cocaine use
5.
Post coronary artery bypass pain
Many causes of chest pain arise from the pleura. Pneumonia with pleurisy, empyema, pulmonary infarction, andneoplasms of the
pleura
must be considered. Tuberculous pleurisy and other infectious agents are not uncommon. Onthe other hand, conditions of the lung are less likely to cause chest pain unless they involve the pleura: This is certainlytrue of pneumonia and neoplasms. A pneumothorax, however, is a very common cause of chest pain, especially inyoung adults.
2
 
Visualize the
heart
and the
pericardium
comes to mind. This is a source of chest pain in acute idiopathic pericarditis,rheumatic carditis, and tuberculous and neoplastic pericarditis. The
myocardium
is the source of the most serious formof chest pain, myocardial infarction, but here again the pain is more severe if the pericardium is involved. Anginapectoris and chronic coronary insufficiency are common causes of chest pain arising from the myocardium. Myocarditis(e.g., viral) causes less severe pain, but inflammation of the myocardium from postinfarction syndrome or postpericardiotomy syndrome can be extremely painful.Now visualize the other central structures: The
esophagus
reminds one of reflux esophagitis and hiatal hernia, the
mediastinum
suggests mediastinitis and substernal thyroiditis or Hodgkin disease (usually not too painful), the
aorta
suggests dissecting aneurysms, and the
thoracic spine
suggests spinal cord tumors, osteoarthritis, Pott disease,fractures, herniated discs, as well as the other conditions listed in Table 14. This chapter would not be complete unless referred pain to the chest was considered. Thus, abdominal conditions suchas cholecystitis, pancreatitis, and splenic flexure syndrome may present with chest pain. Conditions of the neck thatpress the cervical nerves may also cause chest pain, particularly scalenus anticus syndrome, cervical ribs, andherniated discs of the cervical spine:Neurocirculatory asthenia is associated with atypical chest pain; a psychiatric evaluation will assist in this diagnosis.
Approach to the Diagnosis
A possible myocardial infarction must be the first consideration in all adults with acute chest pain especially if there aresignificant alterations of the vital signs. Consequently, serial ECGs, serial cardiac enzymes, and hospitalization will oftenbe necessary. Once this condition has been excluded, we can turn our attention to the other possibilities. Arterial bloodgases, chest x-ray, and a lung scan may be ordered to exclude a pulmonary embolism. Pulmonary angiography may benecessary in some cases. A chest x-ray may be ordered to rule out pneumonia. Acute chest pain related to esophagitisis often relieved by swallowing lidocaine viscus, an extremely useful tool in the differential diagnosis. Relief of the painwith nitroglycerin under the tongue or by spray will support the diagnosis of coronary insufficiency. Tenderness of thecostochondral junctions with relief on lidocaine injection into the point of maximum tenderness suggests Tietzesyndrome (costochondritis). In cases of chronic chest pain, an exercise tolerance test with thallium scan should be doneto rule out coronary insufficiency or myocardial infarct. It may be wise to do immediate coronary angiography if thecondition deteriorates so that balloon angiography, bypass surgery, or reperfusion therapy may be initiated. Dissectinganeurysm is revealed by CT scan or MRI of the chest.===========================================================================
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