20/06/2010

DD Of Chest Pain
• Distinguish between chest pain of
CARDIAC and NON-CARDIAC origin
Case History Considerations
• Presenting complaint

• Past medical History

• Drug, family and social history

Presenting Complaint Is the pain…

Because the causes of chest pain are • Continuous of intermittent
so diverse, a good history is • Duration
important. • Position of pain
• How is it indicated/Quality of the pain
In order to differentially diagnose it is • WF/BF
important to pay particular emphasis -exertion, food, emotion, posture, exercise,
to the characteristic of the Pain. movement, breathing
• Radiation of the pain

Past Medical History Drug, Family & Social History

• History of heart disease • Familial history of heart disease
• History of lung disease
• High Risk Factors
- COAD, phneumothorax, Infection
• History of GIT disease -Heavy smoker/drinker
-Family history / Ethnic Origin
-oesophagitis, ulcers, indigestion, NSAID’s
-Rheumatic fever
• Recent surgery
-Congenital abnormalities
- PE, infection, foreign travel
• Hypertension • Drug history
- risk factors for AAA & Ischemic heart disease

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Differential Diagnosis Of Chest Pain Characteristics Of Different Types Of Chest Pain

System Involved Pathology Characteristic

Myocardial
Pericarditis Pleuritic pain GIT Disease Musculoskeletal
ischemic
MI
Angina Pectoris Crushing, tight or Sharp ( may be Sharp Burning Usually sharp
Cardiac Pericarditis bandlike crushing) may be a dull
Quality of Pain ache
Prolapse of mitral valve

Vascular Aortic dissection Central anterior Central anterior Anywhere Central May be anywhere
chest (usually very
Site of pain localised pain)
PE
Pneumonia
Respiratory Pneumothorax To throat, jaw or Usually no Usually no To throat/ back To arms or
Pulmonary neoplasm arm radiations radiations around chest to
Radiation back
Oesophagitis
Oesophageal tears
GIT Peptic ulcer WF: exertion, WF: lying back WF: breathing, Peptic BF: food WF: pressure on
Biliary disease anxiety,cold BF: sitting forward coughing or Biliary/ chest wall, mvt of
WF/BF
BF: rest and movement oesophageal the neck
Csp root compression
glyceryl trinitrate BF: shallow WF: food BF: cold/hot
Musculoskeletal Costoghondritis breath compresses
Fracture
Sweaty, Fever, recent viral Cough, Excessive wind Other joints
Associated dysponea, illness haemoptysis affected patient
Neurological Herpes Zoster
Symptoms nausea Dysponea looks otherwise
Shock (PE) well

Overview Of Dissection Of the Thoracic Aorta Conditions Predisposing To DVT

Hypertension, bicuspid aortic valve ,pregnancy, Marfrans, Turners, Noonans
Predisposing syndrome. Connective tissue disease, SLE
Factors Men>Women, Middle aged Condition Examples
Damage to the media and high intraluminal pressure causing an intimal tear. Blood
enters and dissects the luminal planes of the media creating a false lumen. Prolonged bed rest for any reason, long air journeys.
Pathophysiology Immobility

Type A: all dissections involving the ascending aorta.

Classification Type B: all dissections not involving the ascending aorta.
Postoperative Abdominal, pelvic, hip and leg surgery.
Central tearing chest pain radiating to the back, further complications as the
Symptoms dissection involves branches of the aorta. Coronary ostia – MI; Carotid or spinal
arteries – hemiplegia, dysphagia or paraplegia; Mesenteric arteries – abdominal pain.
Haemoconcentration Diuretic therapy, Polycythaemia
Patient shocked, cyanosed, sweating. Radial femoral delay. Aortic reguration,
Signs cardiac failure

Hypercoagulable Malignancy, contraceptive pill, protein deficiencies

CXR/CT scan/MRI
Investigations ECG states
Transoesophageal ultrasound

Pain relief, IV drip, BP control. Venous stasis CHD, atrial fibrillation (formation of thrombus in right
Management Sugery Type A. Management and possible surgery type B ventricle = PE)

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