CHEST PAIN DIFFERENTIAL DIAGNOSIS

& MANAGEMENT
 How often do we all come across this
condition in our ER?
 How serious do we all take it?
 Do we differentiate it according to age,

sex, risk factors??

 Do we just presume that it is some kind of

gastric irritation???
 Do we all follow the Red Flags for chest

pain???
 RED FLAGS THAT SHOULD BE
CLEARED OUT IN ER
 ACS  PNEUMOTHORAX
 PE  ACUTE
 PNEUMONIA CHOLECYSTITIS
 CARDIAC  PANCREATITIS
TEMPONADE  PULMONARY
 AORTIC DISSECTION HYPERTENSION
 AORTIC STENOSIS
 MITRAL VALVE
PROLAPSE
 ACUTE CORONARY SYNDROME
HISTORY
 Central chest pain,
squeezing, radiation to jaw
or upper arm, associated
with nausea, vomiting,
dyspnoea, dizziness
 Risk Factors- Smoking,
Age, FHx of CAD, HTN,
Hyperlipidemia, DM,
Stroke, Peripheral Arterial
Disease.
EXAMINATION
 Maybe normal initially.
 Jugular Venous
Distension
 Hypotension,
Tachycardic,
Bradycardic
 Holosystolic Murmur
(Mitral Regurgitation)
 ACS

TESTS
 CXR- Normal/ Signs of heart
 ECG-
failure
1. STEMI- ST Elevation  Cardiac Enzymes- TrpT &
>1mm in 2 limb leads/ ST TrpI. Elevated in STEMI &
Elevation > 2mm in 2 or NSTEMI. Not elevated in
more contiguous chest Unstable Angina.
leads/ New onset LBBB.
 Coronary Angiography-
2. NSTEMI/Unstable STEMI: Critical occlusion,
Angina- ST Depression or NSTEMI/UA: Evidence of
T-wave inversions. narrowing

HISTORY
 H/O CAD, chest discomfort on
exertion, associated with
diaphoresis, nausea/vomiting,
SOB.
 Risk Factors- Same as ACS
EXAMINATION
 No specific findings.
 May have abnormal pulses if
suffering from peripheral vascular
disease.
STABLE ANGINA
TESTS
 ECG- No specific changes. May
have evidence of old MI.
 CXR- Normal/Cardiomegaly.
 Cardiac Enzymes- Not elevated.
 Stress Testing- >1mm ST-
Segment Depression / Elevation
during or after exercise.
 CAG- Evidence of narrowing.
 PULMONARY EMBOLISM
HISTORY EXAMINATION
 Sharp & Pleuritic in nature. In
case of Pulm. Infarction,
 Tachycardia, Tachypnoea.
haemoptysis may occur.
Massive PE can lead to  Fever, if pulmonary
syncope. infarction has occurred.
 Risk Factors- h/o
immobilization, ortho
 Massive PE may cause
procedures, OCP, previous PE, hypotension.
hypercoagulable states, long
distance travel, red & painful  Saturations may be normal
lower limb that is swollen may
be suggestive of DVT.
in most of the cases.
 PE

TESTS

 ECG- Tachycardia, S1Q3T3.  CT Pulmonary

Angiography- Most
 D-Dimer- Non specific if
positive. PE is excluded if specific.
result is negative with a score
of 2 or less than 2 on Modified  2DECHO- Acute RV
Wells Score. Dilatation or
Hypokinesis.
 CXR- Westermark Sign/
Hampton’s Hump/ Pleural
Effusion.
 V/Q Scan- Mismatch.
 PNEUMONIA

HISTORY TESTS
 Productive/Dry cough, fever,  CXR- Infiltration/ Air
pleuritic pain assoc. with SOB.
Bronchograms/ Pleural
 Rigors, myalgias & arthralgias. Effusion.

EXAMINATION  WBC- Elevated with left

shift.
 Breath Sounds- Decreased,
crepts, wheeze, bronchial breath
sounds.  Sputum/ Blood Cultures-
Not an emergency
 Percussion- Dullness. approach.
 Increased Tactile Fremitus.
 CARDIAC TAMPONADE
HISTORY EXAMINATION

 Hypotension.
 Underlying h/o of MI/  Distended Neck Veins.
Aortic Dissection/  Muffled Heart Sounds.
Trauma  Pulsus Paradoxus.

TESTS
 May present as a result of
Hypothyroidism/  ECG- Low-Voltage QRS complex.
Pericarditis.
 CXR- Globular Heart.
 2DECHO- Pericardial effusion
 Also presents with causing collapse of Atria/ Ventricle.
Dizziness/ Dyspnoea/
Fatigue
 AORTIC DISSECTION
HISTORY
 Acute substernal tearing
sensation, with radiation to
interscapular region.
 Migration of pain due to
propagation of the dissection.
 Stroke/ MI due to obstruction
of aortic branches.
 Hypotension due to
tamponade.
 H/O Marfan’s Syndrome/
Ehlers –Danlos Synd/ Syphilis
EXAMINATION
 Unequal pulses/ BP in both
arms.
 New Diastolic Murmur due
to aortic regurgitation.
 Muffled Heart Sounds.
 New Focal Neurological
deficits.
 AORTIC DISSECTION

TESTS

 CXR- Widened Mediastinum/ Double Knuckle Aorta/

Left Pleural Effusion/ Deviation of the Trachea or NG
Tube to the right/ Calcium Sign.

 Transoesophageal Echo- False lumen/ Flap seen in the

ascending or descending aorta.

 CT Chest With Contrast.

 MRI Angiography.

HISTORY
 Pain similar to Anginal Pain,
which is usually progressive.
 SOB/ Syncope.
 Risk of Cardiogenic Shock/
Sudden Death.
EXAMINATION
 Ejection Systolic Murmur
radiating to the neck.
AORTIC STENOSIS
TESTS
 ECG- LVH/ Enlarged P-
Wave.
 CXR- Calcified Aortic
Valve/ Pulm. Oedema.
 2DECHO- Abnormality
in Aortic Valve opening/
LV Systolic Dysfunction.
 MITRAL VALVE PROLAPSE
HISTORY
 Usually asymptomatic.
 May present with chest pain,
palpitations, dyspnoea,
headache, fatigue
EXAMINATION
 Mid-Systolic Click & late
Systolic Murmur at the Apex
TESTS
 ECG- Usually normal.
May show AF or other
arrhythmias.
 CXR- Usually normal.
May show enlarged PA/ LA
(Atrial Escape).
 2DECHO- Mitral
regurgitation & valve
prolapse.
 PNEUMOTHORAX

HISTORY EXAMINATION

 Acute pleuritic chest

 Absent breath sounds.
pain/ SOB/ Tachypnoea/  Percussion- Increased
Tachycardia. resonance.
 Primary Spontaneous- 20-
40yr age.  Jugular venous
 Secondary Spontaneous- distension.
patients with COPD.
 Traumatic.  Tracheal deviation.
 Shock may occur-
Tension Pneumothorax.  Hypotension.
 PNEUMOTHORAX

TESTS

 CXR- Air in pleural space/ Visible pleural

line with collapsed lung/ Mediastinal shift.

 USG- Barcode sign.

 PULMONARY HYPERTENSION

HISTORY EXAMINATION
 Chest pressure or pain on  Jugular venous distension.
exertion

 SOB- initially while exercising,  Lower extremity oedema.

later at rest.
 Ascitis.
 Dizziness/ Syncope

 Bluish color of skin & lips.

 Right ventricular heave.

 Palpitations.  Palpable P2.

 PULMONARY HYPERTENSION

TESTS

 ECG- Right axis deviation/ RVH/ RA

enlargement.

 CXR- Large & prominent pulmonary arteries.

 2DECHO- Tricuspid regurgitation/ RV & RA

dilation/ Pericardial effusion.
 PANCREATITIS

HISTORY EXAMINATION

 Distressed/ diaphoretic/
 Epigastric and
febrile/ tachycardia.
Periumbilical pain that
radiates to the back.  Abdominal tenderness may
present with guarding.
 Associated with nausea
and vomiting.  Ecchymosis in the
Periumbilical region-
 H/O chronic alcohol Cullens Sign/ Flank region-
consumption/ gall Grey-Turner Sign.
stones.
 PANCREATITIS

TESTS

 Serum Lipase- Double the normal value.

 FBC- Leukocytosis.

 Electrolytes & RFT- Elevated creatinine & high anion gap.

 ABG- Acidosis.

 Abdominal USG- To find out the cause.

 Abdominal CT Scan- Stage the severity of pancreatitis.

 ACUTE CHOLECYSTITIS

HISTORY EXAMINATION

 Right upper quadrant  Murphy’s Sign positive.

pain, radiation to the
interscapular region/ right
shoulder.
 Associated with nausea/
vomiting/ fever/
 Abdominal rigidity/
guarding, if the GB gets
perforated.
 Jaundice is very rare in
the early course of
disease.
 ACUTE CHOLECYSTITIS

TESTS

 LFT- Alkaline Phosphatase & GGT are increased.

 FBS- Leukocytosis with Left Shift.

 USG Abd.- Pericholecystic fluid/ distended GB/

thickened GB wall/ Gallstones.
 COSTOCHONDRITIS
HISTORY

 Focal chest wall pain.

 May have a h/o injury.
 Aggravated by sneezing/ coughing/ deep inspiration/ twisting of the
chest.

EXAMINATION

 Pain over the costochondral junction on palpation.

TESTS

 CXR- Normal findings. Then why do we do this???

 ANXIETY OR PANIC DISORDER

HISTORY

 Sharp chest pain with anxiety/ dizziness/ palpitations/ sweating/

trembling/ fear of dying or going insane/ paraesthesiae/ chills/
breathlessness/ carpal spasms.

EXAMINATION

 Apart from Hyperventilation, normal examination.

TESTS

 ECG & CXR- Normal findings.


HISTORY
 Retrosternal burning sensation
after a heavy greasy meal.
 Aggravated by lying down
supine and relieved by sitting up.
 Relieved by antacids.
EXAMINATION
 No specific findings.
GERD
TESTS
 Therapeutic trial- ???
 Oesophagogastroduod-
enoscopy- Oesophageal
inflammation/ Erosions- Not
an ER approach!!
 Oesophageal pH monitoring-
Persistantly low pH (<4) may
be indicative of reflux disease-
Again not an ER approach!!
 PERICARDITIS

HISTORY EXAMINATION

 H/O of viral fever present.  Tachycardia.

 Sharp pleuritic chest pain
provoked by lying supine &  Friction rub.
improved with sitting up.
 Assoc. with dry cough/
fever/ myalgia/ arthralgias.
 Jugular distension &
 H/O radiation exposure/ Pulsus Paradoxus-
collagen vascular disease/ Indicative of what???
recent MI/ uraemia.
 PERICARDITIS

TESTS

 ECG- Diffuse concave up ST-Elevation/ PR depression/

 CXR- Usually normal. Globular heart- Indicative of

what???

 2DECHO- Usually normal or may show pericardial

effusion.
 PEPTIC ULCER DISEASE
HISTORY
 Gastric Ulcer- Epigastric pain/
burning sensation which can be
felt as chest discomfort, usually
5-15min after eating and may
last for several hours.
 Duodenal Ulcer- Epigastric pain
that may be relieved by eating
and can return 1-4hrs
postprandially.
 Risk Factors- Smoking/ Alcohol/
NSAIDs.
EXAMINATION
 Epigastric tenderness.
 In extreme cases where
bleeding occurs- Abdominal
guarding/ tachycardia/
hypotension/ conjunctival
pallor.
TESTS (Not ER approach)
 Oesophagogastroduodeno-
scopy-
 Helicobacter pylori breath
test-
 OESOPHAGEAL SPASM

HISTORY TESTS
 Crushing substernal chest  Barium Swallow-
pain, associated with
dysphagia.
Corkscrew/ Rosary Bead
 Dysphagia precipitated by appearance.
very hot and cold foods.
 Glyceryl Trinitrate can relieve
the pain.

EXAMINATION

 No specific findings.
 GASTRITIS
HISTORY

 Dyspepsia/ epigastric discomfort/ nausea/ vomiting/ loss of appetite.

 H/O alcohol/ NSAIDs/ Helicobacter pylori inf./ previous gastric or
abdom. surgery.

EXAMINATION

 Epigastric discomfort/ signs of B12 deficiency & pernicious anemia.

TESTS

 Helicobacter Pylori Urea Breath Test.

 Endoscopy & Gastric Mucosal Biopsy
 HERPIS ZOSTER
HISTORY

 Unilateral , burning pain along the dermatomal distribution , which may be

followed by appearance of rash .

EXAMINATION

 Vesicular rash on an erythematous base along the dermatomal distribution

only.

TESTS

 Usually no test is required. Diagnosed clinically.

 Swab for Viral Culture & PCR.
 THANK YOU FOR
YOUR ATTENTION.
ANY QUESTIONS??