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EPIDEMIOLOGY
DIAGNOSIS
PRIMARY CARE
EMERGENCY
DEPT
Musculoskeletal
36 %
7%
GIT
19 %
3%
Cardiovascular
Disease
16 %
54 %
Psychosocial
8%
Pulmonary
5%
Nonspecific chest
pain
USA
Statistics
16 %
(Adopted from AAFP)
9%
12 %
15 %
STEPWISE APPROACH TO
CHEST PAIN
Brainstorm for differentials of chest pain
Focused history.
Look for Risk factors for MI /PE/AORTIC
DISSECTION/PNEUMOTHORAX.
Focused physical exam
Labs/Investigations
Management strategy
Establish Differentials
PHYSICAL EXAMINATION
General Appearance
Vital Signs
CVS
RS
Abdomen
KEY LABS
ECG
Blood tests: Cardiac Enzymes,
CBC,ESR,D-dimer,RFT,Clotting
studies.
Imaging: CXR,CT Thorax,Spiral CT
with contrast,U/S Doppler Venous
system legs
LIKELIHOOD OF MI
Work-up
EKG
CXR to look for signs of congestive heart failure
Cardiac enzymes: CK (will begin to rise 6 hours
after infarct and remain elevated for 24-48
hours), troponin (will begin to rise 12 hours after
infarct and remain elevated for 2 weeks). Need to
follow serially if first set negative.
Others for risk factors and baseline function.
TIMI SCORE
TIMI score Mnemonic
AMERICA:
Age > 65
Markers (increased serum cardiac markers)
EKG (ST depression)
Risk factors (3 or more CAD risk factors: patient age (>45
M, > 55 F), family history [CAD in first degree relatives, <55
M, <65 F), hypercholesterolemia, hypertension, smoking,
diabetes, obesity, sedentary lifestyle, metabolic syndrome)
Ischemia (2 or more anginal events over past 24 hours)
CAD (prior coronary stenosis of 50% or more)
Aspirin use within past 7 days
Pulmonary Embolism
Sudden-onset sharp chest pain
Exacerbated by inspiratory effort
Can be associated with hemoptysis, syncope,
dyspnea, calf swelling/pain from DVT
Risk factors: immobilization, fracture of a limb,
post-operative complications, hypercoagulable
states (underlying carcinoma, high-dose
exogenous estrogen administration, pregnancy,
inherited deficiencies of antithrombin III,
activated protein C, S, lupus anticoagulant, prior
history of DVT/PE [Virchows triad]
Pulmonary Embolism
Anxious patient, sense of impending doom
Tachycardia, tachypnea, hypoxia
EKG: sinus tachycardia most common,
S1Q3invertedT3 with large embolus (classic, but
rare!), look for right-axis deviation
V/Q scan very sensitive but not specific
Spiral CT with contrast show large, central emboli
Pulmonary angiogram is gold standard but carries
risk
Consider Doppler U/S of legs
Wells Criteria
. The Wells Score correlates with the probability that a given patient has a pulmonary
embolism. The mnemonic is:Dont die, tell the team to calculatecriteria!
Dont(DVT symptoms) 3 points
Die(Diagnosis most likely PE) 3 points
Tell (Tachycardia) 1.5 points
TheTeam(Three days [at least] of immobilization, or surgery in the pastThirty days)
1.5 points
To (Thromboembolism in the past [DVT or PE]) 1.5 points
Calculate (Coughing up blood [hemoptysis]) 1 point
Criteria (Cancer) 1 point
This is what the scores mean:
> 6Highprobability of PE
2-6Moderateprobability of PE
< 2Lowprobability of PE
The modified Wells Criteria is a bit simpler:
> 4 PE islikely Consider diagnostic imaging.
4 PE isunlikely ConsiderD-dimerto rule out PE.
Pneumothorax
Can be asymptomatic or present with acute
pleuritic chest pain and dyspnea
Primary pneumothorax predominantly in
healthy young tall males
Due to trauma (MVA accidents associated
with rib fractures, iatrogenic during line
placement, thoracentesis)
Increased alveolar pressure from asthma or
barotraumas (BiPAP, ventilator-associated)
Rupture of bleb in COPD patients
Pneumothorax
Decreased expansion of chest
Decreased breath sounds and
Decreased tactile/vocal fremitus on side of
pneumothorax
Hyperresonant percussion note
Usually easily confirmed by CXR
Aortic Dissection
Abrupt onset
The pain usually is described as ripping or tearing
Tearing or ripping pain that is felt in the
intrascapular area
New diastolic murmur, asymmetrical pulses, and
asymmetrical blood pressure measurements
Risk factors: HTN, Marfan syndrome, coarctation of
aorta..
Widened mediastinum on a portable
anteroposterior (AP) radiograph
TEE considered diagnostic test of choice
Boerhaaves Perforation
This is very rare but is associated with a high mortality.
There is a history of sudden onset severe chest pain
immediately after an episode of vomitting
Symptoms may include shortness of breath and pleuritic type
of chest pain (due to subsequent pleurisy and effusion).
Signs of pleural effusion after some hours- dullness to
percussion,absent breath sounds,decreased vocal resonance.
Subcutaneous emphysema in a minority of cases
Abdominal rigidity,sweating,fever,tachycardia and hypotension
may be present as the fever progresses but are non specific.
The way to rule it out if you strongly suspect is to perform a
chest radiograph after swallowing a water soluble contrast
(gastrograffin)
Thank You