CHEST PAIN Liu Zhenhua. GENERAL INFORMATION 50 year-old, Male Bank executive CHIEF COMPLAINT: CHEST...

CHEST PAIN

Liu Zhenhua

GENERAL INFORMATION

• 50 year-old, Male

• Bank executive

CHIEF COMPLAINT: CHEST PAIN

HISTORY OF PRESENT ILLNESSintermittent non radiating substernal chest heaviness precipitated after climbing 2 flight of stairs Grade 3/10Relieved after 5 minutes restRecurring 1x a month

1 year ago

6 months ago

same character of chest pain, recurring every week, precipitated after climbing only one flight of stairs lasting 10-15 minutes relieved by rest Recurring 1x 2 weeks

1 week ago

chest heaviness recurring everyday (grade 6/10) 20-30 minutes durationPrecipitated after walking only 5 to 10 meters relieved by rest

Consultation and subsequent admission

(+) HPN for 5 years: highest BP= 180/100 mmHg; usual BP= 140-150/90 mmHgIrregular intake of amlodipine 5 mg

SALIENT FEATURESSubjective

•50 year old , Male •Bank executive•Hypertensive for 5 years•Progressive substernal chest pain, recurring everyday, grade 6/10 lasting for 20-30 minutes precipitated after walking only 5-10m•Non-compliance to medication•Family history of hypertension, diabetes mellitus and heart problems•Fond of eating steak and bulalo•No regular exercise•smoker- 20 pack years•Alcohol intake

Objective

•BP 170/100•PR 100 per minute•BMI= 31 (obese)

CHIEF COMPLAINT:CHEST PAIN

An unpleasant sensation in the anterior wall of the thorax associated with actual or potential tissue damage and mediated by specific nerve fiber to the brain where conscious appreciation may be modified by various factors

Source: Stedman’s Medical Dictionary 27th Edition

IntroductionIntroduction

• Patients with acute nontraumatic chest pain present a diagnostic challenge

• May appear very ill or completely well

• Significant risk for sudden death or AMI

• Initial assessment should focus on stability

• Consider the 6 structures in the chest

Differential Diagnosis of Chest Pain

• Heart: Acute coronary syndrome (ACS), pericarditis, myocarditis, valvular diseases (especially aortic stenosis)

• Lungs: pneumonia/other infections, pneumothorax, Pulmonary embolism (PE), COPD

• Esophagus: esophagitis, GERD, spasm, foreign body, carcinoma

• Aorta: dissection, aneurysm, aortitis• Upper Abdomen: cholecystitis, pancreatitis, ulcer, hepati

c disease• Chest wall: shingles, costochondritis, contusion, rib fract

ure, muscle strain or tear

Causes

• CardiovascularCardiovascular

• PulmonaryPulmonary

• GastrointestinalGastrointestinal

• MusculoskeletalMusculoskeletal

• NeurologicalNeurological

CARDIOVASCULAR

progressive non radiating chest heaviness

usually occurring for 10-30 minutes

Initially, precipitated by climbing the stairs

lately precipitated by walking 5-10 meters

Source: Bates’ A Guide to Physical Examination and History Taking, 6th edition

Chest Pain

• CardiovascularCardiovascular

• RespiratoryRespiratory




RESPIRATORYPleuritis (pleurisy)Pleuritis (pleurisy)

PneumoniaPneumonia

Lung abcessLung abcess

Pulmonary EmbolismPulmonary Embolism

PneumothoraxPneumothorax

Pulmonary HypertensionPulmonary Hypertension

AsthmaAsthma

• Pleuritis - inflammation or irritation of the pleural membrane; oftinflammation or irritation of the pleural membrane; often caused by infection, pulmonary embolism, pneumothorax, en caused by infection, pulmonary embolism, pneumothorax, arthritis, lupus, or or cancer, manifests as a sharp pain when breathing, coughing, or sneezing

• Pneumonia – fever, chills, productive cough• Pneumonia or lung abcess –causes deep chest ache and possiPneumonia or lung abcess –causes deep chest ache and possi

bly pleuritic painbly pleuritic pain• Pulmonary Embolism – a dislodged thrombus travels through tPulmonary Embolism – a dislodged thrombus travels through t

he bloodstream into the lungs; likely follows deep vein thrombohe bloodstream into the lungs; likely follows deep vein thrombosissis

• Pneumothorax – lung collapse, often caused by injury to the chPneumothorax – lung collapse, often caused by injury to the chest, resulting in release of air into thoracic cavityest, resulting in release of air into thoracic cavity

• Pulmonary Hypertension – abnormally high blood pressure in tPulmonary Hypertension – abnormally high blood pressure in the arteries of the lungs, forcing the right side of the heart to worhe arteries of the lungs, forcing the right side of the heart to work too hardk too hard

• Asthma – inflammation of the airways, causing wheezing, shortAsthma – inflammation of the airways, causing wheezing, shortness of breath, coughing, chest painness of breath, coughing, chest pain

RESPIRATORYNo sharp, burning pain (chest heaviness)

There is specific duration (usually 10-30 minutes

No cough or dyspnea and is relieved with rest


Chest Pain• CardiovascularCardiovascular





GASTROINTESTINALAcid Reflux/ GastroesophAcid Reflux/ Gastroesophageal Reflux Disease (Gageal Reflux Disease (GERD) – ERD) – ““heartburnheartburn””

Occurs when stomach Occurs when stomach contents, specifically gastric contents, specifically gastric juices, move back up to the juices, move back up to the esophagus and possibly even esophagus and possibly even up to the throatup to the throat

Esophageal Contraction Esophageal Contraction Disorders Disorders

uncoordinated muscle uncoordinated muscle contractions (spasms), high-contractions (spasms), high-pressure contractions pressure contractions (nutcracker esophagus)(nutcracker esophagus)

Esophageal HypersensitiEsophageal Hypersensitivity vity

esophagus becomes very esophagus becomes very sensitive to even small changes sensitive to even small changes in pressure or exposure to acidin pressure or exposure to acid

• Gastroesophageal reflux disease (GERD) – similar to angina because esophagus and heart are located close to each other and they share a nerve network

• OthersOthers– Esophageal Contraction DisordersEsophageal Contraction Disorders– Esophageal HypersensitivityEsophageal Hypersensitivity– Esophageal CarcinomaEsophageal Carcinoma– Esophageal RuptureEsophageal Rupture– Hiatal Hernia – stomach herniates into the diaphragmHiatal Hernia – stomach herniates into the diaphragm– PancreatitisPancreatitis– Lung abcessLung abcess– Gallbladder problemsGallbladder problems

GASTROINTESTINAL

no squeezing pain (chest heaviness)

There is specific duration (usually 10-30 minutes)

not aggravated by food intake, relieved by rest


MusculoskeletalMusculoskeletal


Cause by:Bone Pain – ribs or sternum may be fracturedMuscle Strain – may be caused by excessive coughing

no stabbing, dull, localized pain (chest heaviness)

there is specific duration (usually 10-30 minutes)

not aggravated by twisting upper body, and relieved with rest

Neurological


NeurologicalNeurologicalShingles – caused by varicella zoster virus; causes nerve pShingles – caused by varicella zoster virus; causes nerve pain in chest areaain in chest areaPsychologicalPsychologicalAnxiety or panic attacksAnxiety or panic attacks

no visceral tightness, precordial, L breast pain (chest heaviness)

usually occurs < 30 minutes

not aggravated by emotional stress

System Quality Location Aggravated by

Relief

Cardio-

vascularHeaviness Crushing

Substernal across the anterior chest, radiating to (L) arm

Exertion Rest

References: Mosby’s Guide to Physical Examination, 6th edition. Harrison’s Principles of Internal Medicine 17th edition

CardiovascularAngina Discomfort that occurs as a Discomfort that occurs as a

result of cardiac muscle result of cardiac muscle ischemia caused by ischemia caused by blockage of coronary arteriesblockage of coronary arteries and chest discomfort usually described as heaviness, pressure, squeezing, smothering, or choking painpain

• Typically caused by exertion or emotion• Crescendo-decrescendo in nature, 2-5 mins, radia

tes• **Levine’s sign - when the patient is asked to local

ize pain, he or she will typically press on the sternum sometimes with a clenched fist, to indicate a squeezing, central, substernal discomfort

• Radiates to L shoulder especially to the ulnar surfaces of the forearm and hand. May also radiate to the back, interscapular region, root of the neck, jaw, teeth and epigastrium

Cardiovascular

Myocardial Infarction Myocardial Infarction (heart attack) (heart attack)

may be similar to angina but MI pain may be similar to angina but MI pain is more severe and crushing, not is more severe and crushing, not relieved by rest, may be relieved by rest, may be accompanied by sweating, nausea, accompanied by sweating, nausea, and/or severe weaknessand/or severe weakness

Aortic DissectionAortic Dissection Tear in the intima of the aorta. Blood Tear in the intima of the aorta. Blood “dissects” between the layers of the a“dissects” between the layers of the arterial wall. Most severe at onset. Cuttrterial wall. Most severe at onset. Cutting, searing, ripping, tearinging, searing, ripping, tearingRetrosternal and interscapularRetrosternal and interscapular

MyocarditisMyocarditis may be accompanied by fever, may be accompanied by fever, fatigue, trouble breathingfatigue, trouble breathing

Pericarditis Pericarditis causes sharp, stabbing, steady pain causes sharp, stabbing, steady pain along upper neck and shoulder along upper neck and shoulder muscle; infection/inflammation of muscle; infection/inflammation of pericardial sacpericardial sac

Hypertrophic Cardiomyopathy Hypertrophic Cardiomyopathy thickening of cardiac musclethickening of cardiac muscle

Differential Diagnosis of Chest Pain

• Heart: ACS, pericarditis, myocarditis, valvular diseases (especially aortic stenosis)

• Lungs: pneumonia/other infections, pneumothorax, PE, COPD

• Esophagus: esophagitis, GERD, spasm, foreign body, carcinoma

• Aorta: dissection, aneurysm, aortitis• Upper Abdomen: cholecystitis, pancreatitis, ulcer, hepati

c disease• Chest wall: shingles, costochondritis, contusion, rib fract

ure, muscle strain or tear

CHEST PAIN Liu Zhenhua. GENERAL INFORMATION 50 year-old, Male Bank executive CHIEF COMPLAINT: CHEST...

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