Approach to a case of chest pain

Approach to a case of chest pain


Initial diagnostic assessment and triage is made around three categories: -
a) Myocardial Infarction
b) Cardiopulmonary causes
                         1) Pericardial diseases
                         2)Aortic emergencies
                        3) Pulmonary conditions
c) Non cardiopulmonary causes

Most common cause- Gastrointestinal diseases

Causes of chest discomfort

  • Gastrointestinal (oesophageal reflux, oesophageal spasm, peptic ulcer disease) 
  •  Ischemic heart disease 
  • Chest wall syndrome 
  • Pericarditis  
  • Pleuritis  
  • Pulmonary embolism  
  • Lung cancer  
  • Aortic aneurysm  
  • Aortic stenosis  
  • Herpes zoster  
  • Costrochondritis
  • Cervical rib
  • Trauma

How to Approach ?

History

In case of non traumatic chest pain
Pain-Quality, Location and radiation, Pattern(onset and duration) , Provocative and alleviating factors ,associated symptoms. 

Quality of pain

  • Pressure or tightness-MI(some patients may deny any pain and some may have only dyspnoea or vague anxiety) 
  • Steady ,severe pressure or aching-Massive pulmonary embolism, Pericarditis
  • Tearing or ripping -Acute aortic dissection
  • Sharp stabbing-Pleuritic chest pain
  • Burning type-Acid reflux , Peptic Ulcer disease, Esophageal pain with spasm

Location of pain

  • MI-Substernal pain radiating to neck, jaw, shoulder, arms. 
  • Oesophageal pain-retrosternal
  • Aortic dissection-Severe pain radiating to back between shoulder blades
  • Pericardial pain radiates to trapezial ridge

Pattern of pain 

  • MI-builds in minutes, increased on activity and decreases on taking rest
  • Aortic dissection, Pulmonary embolism, Spontaneous pneumothorax-Pain reaches peak intensity immediately
  • Fleeting pain-for only few seconds

Provocative and Alleviating factors

  • MI- decreases on rest ( except warm up angina) 
  • Musculoskeletal- Altered intensity with changes in position
  • Pericarditis-worse in supine and sitting position but decreases on leaning forward and upright position
  • GE reflux-Aggravated by alcohol, some food or reclined position
Pain increased on eating- Peptic ulcer disease, Acute pancreatitis and cholecystitis, Coronary artery disease (due to redistribution to splanchic vasculature) 

Associated symptoms

  • MI-Dyspnoea, diaphoresis, nausea ,fatigue, faintness, syncope, pre-syncope etc. 
  • Pulmonary embolism-Haemoptysis, syncope
  • Severe heart failure-blood tinged frothy sputum
  • Nausea and vomiting-MI(activation of vagal reflex) 

Past Medical History


Physical Examination

General

Patient-Anxious, uncomfortable, pale, cyanotic, diaphoretic-MI, Acute cardiopulmonary disorder
Levine's Sign

Vitals

Tachycardia, hypotension-Acute MI, Cardiigenic Shock, Pericarditis with Tamponade, Massive pulmonary embolism, Tension pneumothorax

Severe Hypertension or hypotension-Aortic emergencies

Sinus Tachycardia-Submassive Pulmonary embolism

Tachypnoea and hypoxemia-Pulmonary cause

Systemic Examination

Pulmonary System-Findings can localise a primary pulmonary cause of chest discomfort like asthma, pneumothorax, pneumonia

Cardiac-S3 or S4 heared in myocardial dysfunction
                Cardiac murmers and Pericardial rub

Abdominal - Localised tenderness
                     Right Ventricular Dysfunction-Hepatic congestion

Vascular
   Pulse deficit-Chronic Atherosclerosis
   Aortic dissection leads to acute limb ischemia with loss of pulse and pallor

Musculoskeletal System
   -Pain arising from costrochondral and          chondrosternal articulation is associated with localized swelling ,redness, tenderness. 

Investigations

ECG
Chest X ray
Cardiac Biomarkers
CT angiography



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