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



Comments

Post a Comment

Popular posts from this blog

What is dysphagia?

What is Dysphagia ?  Dysphagia can be defined as the difficulty in swallowing.  Causes of Dysphagia Preoesophageal causes Preoesophageal causes may be due to disturbance in oral or pharyngeal phase of deglutition, which include following: - Disturbance in mastication Disturbance in lubrication Disturbance in mobility of tongue Defects of palate Lesion of buccal cavity and floor of mouth Obstructive lesions of pharynx Inflammatory conditions Spasmodic conditions Paralytic conditions Oesophageal causes When their is disturbance in the oesophageal phase of deglutition. Their may be problem in lumen, in the wall or outside the wall of oesophagus.  Obstruction in lumen due to atresia, foreign body ,strictures or any tumour Acute or chronic oesophagitis Motility disorders of oesophagus Lesions pressing on the oesophagus from outside, for eg. Hiatus hernia, cervical osteophytes, mediastinal lesions etc.  Investigations Detailed history and examinatio
Read more

Gastric Outlet Syndrome

Image
Gastric Outlet Syndrome Definition Gastric outlet syndrome occurs due to obstruction at gastric outlet.  Causes Pyloric stenosis secondary to peptic ulcer disease Gastric Cancer Adult pyloric stenosis Pyloric mucosal diaphragm Clinical Features There is long history of peptic ulcer disease Remitting pain Non bilious vomiting Loss of weight Dehydration Metabolic Effects Hypochloraemic alkalosis  Dehydration leading to renal dysfunction Tetany due to alkalosis Hyponatremia Management Correct metabolic abnormality Patient rehydrated with IV isotonic saline along with potassium supplements Stomach should be emptied with a wide bore gastric tube Endoscopic biopsy to detect malignancy Aggressive medical therapy for peptic ulcer disease  Endoscopic dilation of gastric outlet in less severe stenosis Operation is frequently required Drainage for benign disease and resection for malignant disease. 
Read more

Headache

Image
Headache Origin of headache:  Stimulation of peripheral nocioreceptors due to tissue injury Damage of pain producing pathways of peripheral or central nervous system.  COMMON CAUSES of HEADACHE Primary Headache         Secondary Headache  Tension-type                    Systemic infection Migraine                            Head injury Idiopathic stabbing        Vascular disorders Exertions                          Subarachnoid Hemorrhage Cluster                               Brain tumour Pain producing cranial structures: Scalp, Middle meningeal artery, Dural sinuses, Falx cerebri, Proximal segments of large pial arteries.  Headache is of two types:  Primary Headache Definition:Here, headache and it's associated features are disorder in itself(without any exogenous cause) .  Structures involved Large intracranial vessels and dura matter Peripheral terminal of trigeminal nerve innervating these structures Caudal portion of trigeminal ner
Read more