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Table 8-2 -- Causes and Differentiation of Potentially Catastrophic Illness Presenting with Central Chest Pain or Discomfort Prevalen Associate

ce in Physical Atypical or d Supporting Emerge Useful Pain History Examinati Additional Symptom History ncy Tests on Aspects s Departm ent Patients are anxious, restless, uncomforta ble, and may be confused. Blood pressure is usually Discomfort is elevated usually but moderately normotensi severe to May be on and severe and precipitated hypotensio rapid in by emotional n are seen. onset. May stress or The heart be more exertion. rate is “pressure” Prodromal usually than pain. pain pattern increased, Usually often but Diaphoresi retrosternal, elicited. bradycardi Myocardial s, nausea, may radiate Previous Common a can be infarction vomiting, to neck, jaw, history of MI noted. dyspnea both arms, or angina. Patients and sides of Over 40 may be chest (left years old, diaphoretic more than positive risk and show right). Lasts factors, and peripheral more than male sex poor 15–30 min increase perfusion. and is possibility. There are unrelieved no by diagnostic nitroglycerin examinatio n findings for MI although S3 and S4 heart sounds and mitral regurgitant murmur are supportive. Unstable angina Changes in pattern of preexisting angina with Often minimal Not clearly Nonspecifi related for c findings Common precipitating of a factors transient Pain may present as “indigestion” or “unable to describe.” Other atypical presentations include altered mental status, cerebrovascula r accident, angina pattern without extended pain, and severe fatigue. Elderly may present with weakness, congestive heart failure, or chest tightness. Twenty-five percent of nonfatal MIs are unrecognized by patient.

ECG changes (new Q waves or ST segment T wave changes) occur in 80% of patients. Use of cardiac enzymes (CPK-MB, troponin) in selected populations (e.g., elderly, patients presenting late in course) has demonstrat ed benefit.

The pain may have resolved by the time of evaluation.

Often no ECG or enzyme changes

May be pain free at presentation.

May be a decrease in amount of physical activity that initiates May have pain. Fifty percent of proximal dissections cause aortic insufficienc y. or frequent pain (crescendo angina). mild Previous diaphoresi history of MI s. Other ECG usually shows left ventricular hypertrophy . peripheral neuropathy . In 50– 60% of cases there is asymmetri c decrease or absence of peripheral pulses. Marfan’s Rare syndrome and bicussid aortic congenital valves have increased incidence. may have similar cardiac findings as in MI. It is rare for patient to present pain free. and male sex increase probability. Fewer than 15% of patients hospitalized for unstable angina go on to acute MI. 24% die in 1 day. nausea. abdominal and extremity ischemia possible Median age is 59 years. paresis or paraplegia.Prevalen Associate ce in Physical d Supporting Emerge Pain History Examinati Symptom History ncy on s Departm ent more severe. Pain often migrates with a “tearing” sensation nature. dyspnea Over 40 with pain years old. Pattern of pain change important in gauging risk for acute MI. at rest. Variant angina (Prinzmetal’s) has episodic pain. prolonged. 50% in 1 week. often severe. May manifest similarly to non–Q wave infarction. Neurologic complicatio ns of stroke. . presence of risk factors. 3:1 ratio males to females. Pain usually lasts > 10 min. Radiates Aortic anteriorly in dissection chest to the back interscapular area or into abdomen. History of hypertension in 70%–90% of patients. Useful Tests Atypical or Additional Aspects Full history is essential. or angina. May respond to nitroglycerin. with prominent ST segment elevation. Angina at rest lasting 15– 20 minutes or new-onset angina (duration less than 2 months) with minimal exertion. nonspecific changes. Often poorly perfused peripherall y but with elevated BP. May present with neurologic complications. Unpredictabl e responses to nitroglycerin and rest Ninety percent of patients have rapidonset severe chest pain that is maximal at beginning.

. Severe abdominal pain can be the primary complaint. often immobile.Prevalen Associate ce in Physical d Supporting Emerge Pain History Examinati Symptom History ncy on s Departm ent vascular occlusions: coronary (1–2%). Useful Tests Atypical or Additional Aspects Chest film shows abnormal aortic New-onset silhouette pericardial (90%). Abrupt in onset and maximal at beginning Usually some period Dyspnea of and immobilizati apprehensi on has on play a occurred. Emboli usually from lower extremities above knee. oligemia. Arterial blood gases show PO2 <80 mm Hg in 90%. ∼15% of pulmonary embolisms have normal (Aa)O2. right side of heart. friction rub or aortic Aortic insufficienc angiograph y murmur y has supportive diagnostic of accuracy of diagnosis 95%–99%. or signs of consolidatio n. Descending are generally managed medically. CT. Ascending aortic aneurysms are approached more surgically.g. Ultrasound. prostate/pelvis venous plexus. although up to 40% show some volume loss. Patients may present with dyspnea with or without bronchospasm. Physical examination findings may be minimal. role. spinal cord. mesentery. previous history) Patients are Rare in anxious ambulato and have a ry respiratory patients rate over 16 breaths per minute. . Pain is more often lateralpleuritic. MRI most useful in screening. prominent (e. more than without pain. Central pain is more Pulmonary consistent Embolism with massive embolus. Dissection into coronary arteries can mimic MI. renal. Acute mortality rate is 10%. Chest film is usually normal.

Decreased breath sounds. . oral contraceptiv es. Tension pneumotho rax should be diagnosed on physical examinatio n. Most often Pneumoth lateralorax pleuritic. increased resonance on percussion . phlebitis. and previous embolus are all risk factors Lung perfusion scan rules out. if negative and low probability. Pain is usually acute and maximal at onset. Inspiratory and expiratory films may enhance contrast between air and lung parenchym a. and an increased pulmonic second sound are common. Can be complicated by pneumomedias tinum Pain is Diaphoresi Older Esophage usually s. thrombophle bitis. Chest film definitive. but central pain can occur in large pneumothor aces. asthma.Prevalen Associate ce in Physical d Supporting Emerge Pain History Examinati Symptom History ncy on s Departm ent Tachycardi a. and diaphoresi s are seen in 30%– 40% of patients. Hypotensio n and altered mental states occur in tension pneumotho rax. Elevated pressure in neck veins and tracheal deviation occur in tension pneumotho rax. Angiogram definitive. cystic fibrosis. or asthenic body type Infreque nt May be subtle in COPD. with known Rare Signs of Chest film Patient may lung usually has present in consolidati mediastinal shock state. Angina-like pain may occur in 5% Dyspnea has a prominent role. Spinal CT improving yield. Chest trauma. Hemoptysi s occurs in less than 20%. dyspnea individual al rupture preceded by (late). inspiratory rales. Fever. Wheezes and peripheral cyanosis are less common Useful Tests Atypical or Additional Aspects Cough accompani es about half the cases. previous episode. heart disease. Pregnancy.

pneumotho rax. foreign body. History of violent emesis. and increased by swallowing and neck flexion. magnetic resonance imaging. Useful Tests Atypical or Additional Aspects This entity is often considered late in differential diagnostic process. computed tomography. caustic ingestion. Diagnosis supported by watersoluble contrast esophagogr am or esophagos copy COPD. chronic obstructive pulmonary disease.0. myocardial infarction. a leftsided pleural effusion. air. .Prevalen Associate ce in Physical d Supporting Emerge Pain History Examinati Symptom History ncy on s Departm ent vomiting and shock is abrupt in onset. or a widened mediastinu m. gastrointesti nal problems. CT. MRI. MI. pH of pleural effusion is < 6. Pain is persistent and unrelieved. localized along the esophagus. or blunt trauma on and subcutane ous emphysem a may be present.