Common acute - chest pain.pdf

Differential Diagnosis of Acute Chest Pain Cause Differentials Classical history Classic examination findings Investigation findings Definitive management grouping (Initial test, diagnostic test) (remember ABCDE first) Cardiac ACS ãCrushing central chest pain ãMay be nor
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  © 2015 Dr Christopher Mansbridge at, a source of free OSCE exam notes for medic al students’  finals OSCE revision Differential Diagnosis of Acute Chest Pain Cause grouping Differentials Classical history Classic examination findings Investigation findings (Initial test, diagnostic test)   Definitive management (remember ABCDE first) Cardiac ACS ã Crushing central chest pain ã Radiates to neck/left arm ã Associated nausea/SOB/sweatiness ã Cardiovascular risk factors ã May be normal ã General: sweaty, SOB, in pain ã CVS: S4 gallop, JVP distension, signs of heart failure, brady/tachycardic ã ECG: ST elevation (or new LBBB), inverted T waves, Q waves ã Troponin: increased (butnormal in unstable angina) ã CXR: normal or signs of heart failure ã Coronary angiography ã MONAC ã Primary coronary intervention Aortic dissection ã Tearing chest pain of very sudden onset ã Radiates to back ã Pain in other sites e.g. arms, legs, neck, head ã Unequal arm pulses or BPs ã May be acute aortic regurgitation ã May be new neurological symptoms due to involvement of carotid/vertebral arteries ã CXR: widened mediastinum ã CT angio or transoesophageal echo ã ECG: may be signs of MI ã Type A →  surgical repair ã Type B →  BP controlPericarditis ã Retrosternal/precordial pleuritic chest pain ã Relieved by sitting forward ã May radiate to trapezius ridge/neck/shoulder ã Viral prodrome common ã Pericardial rub (stepping in snow) ã Tachycardia ã JVP distension and pulsus paradoxus may indicate tamponade Clinical diagnosis ã ECG: PR depression, saddle-shaped ST elevation ã CXR: may be globular heart if pericardial effusion present ã Echo: if pericardial effusion suspected ã NSAIDs ã Treat cause (if known)Myocarditis ã Chest pain ã Palpitations ã Fever ã Fatigue ã Dyspnoea ã Signs of congestive cardiac failure ã Soft S1, S4 gallop ã Fever ã Tachypnoea ã ECG: diffuse T wave inversions, ST elevation/depression ã Inflammatory markers: raised ã Troponin: raised ã Serology: identify cause ã Myocardial biopsy (if required) ã Supportive ã Bed rest Other cardiac differentials Stable angina; tamponade; mitral valve prolapse; pulmonary hypertension; aortic stenosis; arrhythmias   Respiratory Pulmonary embolism ã Pleuritic chest pain ã Dyspnoea ã Haemoptysis ã Risk factors (long haul flight, recent surgery, immobility) ã CVS: tachycardia, JVP distension, RV heave, loud P2, right S4 ã RS: tachypnoea, clear chest ã CALVES: look for DVT ã SBP<90/pulselessness/persistent bradycardia = “massive PE”   ã D-Dimer (if low Wells score): raised ã CT pulmonary angiogram ã ECG: tachycardia, RV strain (T wave inversion in right chest and inferior leads), RBBB, right axis deviation, S1Q3T3 pattern rare ã ABG: hypoxia, hypocapnia ã CXR: may be wedge opacity, regional oligaemia, enlarged pulmonary artery, effusion ã Treatment dose LMWH ã Thrombolysis if massive PEPneumonia ã Fever ã Shortness of breath ã Productive cough ã Pleuritic chest pain ã Confusion ã Tachypnoea, cyanosis ã Coarse crepitations and bronchial breathing ã Dullness to percussion ã Increased vocal resonance/tactile vocal fremitus ã CXR: consolidation, air bronchogram ã Inflammatory markers: raised Identify cause ã Sputum culture ã Urinary pneumococcal and legionella antigens ã Blood culture ã Antibiotics Pneumothorax ã Sudden onset pleuritic chest pain ã May be SOB if large ãRisk factors e.g. Marfan’s appearance, COPD/asthma Ipsilateral ã Reduced chest expansion ã Absent breath sounds ã Hyperresonance Tension pneumothorax ã JVP distension, hypotension ã Tracheal deviation (away from affected side) ã CXR: air in pleural spacePrimary ã <2cm →  CXR monitoring ã>2cm  or Sx → aspirate  Secondary ã <1cm →  observe for 24h ã 1-2cm → aspirate ã>2cm  or Sx → chest drain  Pleurisy ã Pleuritic chest pain ã May be: dry cough, fever, dyspnoea ã Pleural rub Clinical diagnosis ã CXR: exclude pneumothorax, effusion and pneumonia ã NSAIDS ã Treat cause (if known) ã Treat complications (effusion, pneumothorax) Other respiratory differentials Lung cancer   Other Musculoskeletal ã Sharp chest pain ã Exacerbated by movement andinspiration ã Can point to where it is worse ã Exacerbated by pressure over area ã Tenderness over area of pain ã Normal exam otherwise Diagnosis of exclusion ã D-dimer: exclude PE ã CXR: exclude pneumothorax and infection ã Inflammatory markers: normal ã Analgesia ã Deep breathing exercises to prevent infection Costochondritis ã Costosternal joint pain ã Worse with coughing, twistingand physical activity ã Tenderness at sternal edges ã Normal exam otherwise Diagnosis of exclusion ã ECG: exclude MI ã Troponin: exclude MI ã CXR: normal ã NSAIDs ã Physical therapyGastro-oesophagleal reflux disease ã Retrosternal burning chest pain ã Related to meals, lying, straining ã Water brash ã Usually normal ã May be epigastric tenderness if associated gastritis Clinical diagnosis ã ECG: exclude MI ã OGD (if red flags) ã Oesophageal pH monitoring (if diagnostic uncertainty) ã Lifestyle advice ã Antacids or PPI  © 2015 Dr Christopher Mansbridge at, a source of free OSCE exam notes for medic al students’  finals OSCE revision Anxiety/panic attack ã Tight chest pain, SOB, sweating, dizziness, palpitations, feeling of impending doom ã Anxious personality & other symptoms of generalised anxiety disorder ã Recurrent episodes triggered by a stimulus (e.g. crowds) ã Usually normal ã May be hyperventilation Clinical diagnosis ã ECG: exclude MI ã Troponin: exclude MI ã CXR: exclude infection ã Reassurance ã CBT Oesophageal spasm ã Intermittent crushing sub-sternal pain ã Relieved by GTN ã Associated dysphagia ã Normal ã Barium swallow: corkscrew oesophagus ã Oesophagral manometry   ã Avoid precipitating foods ã Try: PPI, nitrates, Ca 2+  blockers, phosphodiesterase inhibitors, antidepressants Other differentials  Gastritis; peptic ulcer disease; acute cholecystitis; gastritis; pancreatitis; fibromyalgia; Tietze syndrome
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