Differential

of The Chest Pain

Keluhan paling sering utk Penyakit Jantung

- Tapi banyak Non Cardiac

History

sangat penting

Terus menerus/kadang-kadang
Lamanya
Posisi Tubuh
Pemicu : exercise, emosi, Food,
posture, movement, breathing
Penjalaran
Kwalitas : crushing, burning, stabbing

1.
2.
3.
4.
5.

PJK
Gastric problem
Post Operasi Thorax
Pericarditis
Hipertensi, DM

System Involved

Pathology

Cardiac

Myocardial Infarction
Angina Pectoris
Pericarditis
Prolapse of the mitral valve

Vascular

Aortic dissection

Respiratory (all tend to give rise

to pleuritic pain)

Pulmonary embolus
Pneumonia
Pneumothorax
Pulmonary neoplasm

Gastro Intestinal

Oesophagitis due to gastric reflux

Oesophageal tear
Peptic Ulcer
Biliary disease

Musculoskeletal

Cervical nerve root compression

by cervical disc
Costochondritis
Fractured rib

Neurological

Herpes Zoster

Inspeksi :

Shock : pucat, keringat

infarction

myocardial
dissecting

aorta
pulmonal embolism
Nafas tampak berat
heart failure
Mual, muntah
gastric problem
Batuk
heart failure, pneumonia

Pulse & blood pressure : hipo &

hipertensi, bradycardia, tachicardia,
irreguler pulse
Pucat, Cyanosis
JVP (jugular venous pressure)
Carotid pulse waveform
Apex cardis
Pericardial rub, S III, murmur

Characteris
tic

Myocardial
ischemia

Pericarditis

Pleuritic
pain

Gastrointestin
al pain

Musculoskele
tal

Aortic
Dissection

Quality of pain

Crushing, tight or
bandlike

Sharp (may be
crushing)

Sharp

Burning

Usually sharp
although can be
a dull ache

Sharp,
stabbing,
tearing

Site of pain

Central anterior
chest

Central
anterior

Anywhere
(usually very
localized pain)

Central

Can be anywhere

Retrosternal,
interscapular

Radiation

To throat, jaw or
arms

Usually no
radiation

Usually no
radiation

To throat

To arms or
around chest to
back

Usually no
radiation

Exacerbating &
relieving
factors

Exacerbated by
exertion, anxiety,
cold, relieved by
rest & by gliceryl
trinitrate

Exacerbated
when lying
back; relieved
by sitting
forward

Exacerbated by
breathing,
coughing or
moving; relieid
when breathing
stops

Peptic ulcer pain

often relieved by
food & antacids;
cholecystitis &
oesophageal pain
are exacerbated
by food

Can be
exacerbated by
pressing on chest
wall or moving
neck

Constant with
no
exacerbating
or relieving
factors

Associated
feature

Patient often
sweaty, breathless
& shocked, might
feel nauseated

Fever, recent
viral illness
(e.g. rash,
athralgia)

Cough,
haemoptysis,
breathlessness;
shock with
pulmonary
embolus

Excessive wind

Other affected
joints; patient
otherwise looks
very well

Unequal
radial &
femoral pulse
& blood
pressure;
aortic
regurgitant
murmur may
be heard on
auscultation

Neck
carotiud waveform
elevated JVP
and waveform

BP
hypotension (shock)
hypertension
different between
extremities
Pulse
arrhythmia (tachy- or
brady- )
difference between
extremities

eyes
xanthelasma
(hypercholesterolaemi
a)
Face
pallor
(anaemia)
cyanosis
Heart
murmur of AR (dissection) or AS
(angina)
pericardial rub
audible murmur of MR (MI)
3rd heart sound (MI & LVF)
right ventricular heave &
loud P2 (pulmonary embolus)
displaced apex beat
Lungs
pleural rub
bronchial breathing
reduced breath
sounds
Abdomen
abdominal tenderness or
guarding
reduced bowel sounds

o
o
o
o
o

DL
Cardiac biomarkers : CKMB, Troponin T
Fungsi Renal
Blood Gas
LFT (liver function tests)

EKG
Thorax Foto
Echocardiography
CT Scan
MRI
Exercise tolerance test

Test

Diagnosis

ECG

If normal excludes MI, although evidence for

this may emerge upon observation

CXR

Widened mediastinum suggest aortic

dissection, may show pleural effusion or
pulmonary consolidation

Biochemical
markers

May be normal in first 4 hour after MI, but CKMB, cardiac troponins will then increase

Arterial blood
gases

In the dyspnoeic patient severe hypoxaemia

suggest pulmonary embolus, LVF or pneumonia

CT scan

Carry out urgently for suspected aortic

dissection

CK-MB, creatine kinase compose of M (muscle) & B (brain)

subunits, which is found primarily in cardiac muscle; CT,
computed tomography; CXR, chest radiography; ECG,
electrocardiography; LVF, left ventriculer failure; MI,
myocardial infarction

Chest
Chest pain
pain

At
At rest
rest

Worse
Worse on
on
exertion
exertion
Investigate
Investigate for
for angina
angina
pectoris
(i.e.
serial
pectoris (i.e. serial
ECG,
ECG, coronary
coronary
angiogram)
angiogram)

Consider
Consider
pulmonary
pulmonary
embolus
embolus in
in all
all
patients
patients

Not
Not worse
worse
in
in
inspiration
inspiration

Pleurisy
Pleurisy scondary
scondary to
to
pneumonia,pneumoth
pneumonia,pneumoth
orax,
orax, pulmonary
pulmonary
embolus,
embolus, dresslers
dresslers
syndrome
syndrome

Raised
Raised
ST
ST
segment
segment

Consider
Consider
MI
MI

Worse
Worse in
in
inspirati
inspirati
on
on

Central
Central
pain
pain
ST
ST depression
depression
T
T Wave
Wave
inversion
inversion
T
T Wave
Wave
flattening
flattening
Consider
Consider unstable
unstable angina
angina
and
investigate
and investigate further
further
(i.e.
(i.e. serial
serial ECGs,
ECGs, serial
serial
biochemical
markers,
biochemical markers,
excersie,
excersie, coronary
coronary
angiogram
angiogram

Widespread
Widespread
concave
concave ST
ST
elevation
elevation

Pericarditi
Pericarditi
s
s

Musculoskele
Musculoskele
tal
tal
oesophagitis
oesophagitis

Lateral
Lateral

Musculoskele
Musculoskele
tal
tal shingles
shingles
(herpes
(herpes
zoster)
zoster)

Thank
you