bol u grud uvod

7/27/2019 bol u grud uvod

1/17

Assessment of chest painOverview

Summary

Aetiology

Emergencies

Urgent considerations

DiagnosisStep-by-step

Differential diagnosis

Guidelines

Resources

References

Images

Patient leaflets

Credits

Email

Print

Feedback

ShareAdd to Portfolio

Bookmark

Add notes

SummaryChest pain is a common chief complaint, accounting for 5% to 8% of all emergency department visits in the US

per year,[1] and is the presenting complaint in 1% to 2% of office-based visits.[2] In general practice in the UK,

the incidence of newly diagnosed chest pain is 15.5 per 1000 person-years.[3]

Chest pain may be caused by either benign or life-threatening aetiologies and is usually divided into cardiac and

non-cardiac causes. Acute coronary syndrome (ACS) encompasses unstable angina and MI. ACS affects only a

few of the patients presenting with chest pain, but excluding ACS is vital because of the mortality associated with

untreated MI. This monograph concentrates on the assessment of chest pain in the emergency setting.

Differential diagnosisSort by: common/uncommonorcategoryCommon

Acute coronary syndrome

Stable angina

Pulmonary embolism

Pneumonia

Viral pleuritis

GORD

Costochondritis

Anxiety or panic disorder

Uncommon

Pericarditis
http://bestpractice.bmj.com/best-practice/monograph/301/overview.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/aetiology.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/emergencies.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/emergencies/urgent-considerations.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/step-by-step.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/guidelines.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/patient-leaflets.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/credits.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/feedback/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/share/301/overview/summary.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Chest+pain+(Assessment+of)+-+Summary&dataValue=%2Fbest-practice%2Fmonograph%2F301.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-2http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-2http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-2http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/summary/by-category.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-1http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-2http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-8http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-11http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-13http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-18http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-20http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-3http://bestpractice.bmj.com/best-practice/monograph/301/overview.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/aetiology.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/emergencies.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/emergencies/urgent-considerations.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/step-by-step.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/guidelines.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/patient-leaflets.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/credits.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/feedback/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/share/301/overview/summary.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Chest+pain+(Assessment+of)+-+Summary&dataValue=%2Fbest-practice%2Fmonograph%2F301.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-2http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/summary/by-category.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-1http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-2http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-8http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-11http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-13http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-18http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-20http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-3


2/17

Cardiac tamponade

Aortic dissection

Aortic stenosis

Mitral valve prolapse

Pneumothorax

Pulmonary hypertension

Peptic ulcer disease (PUD)

Oesophageal spasm

Acute cholecystitis

Pancreatitis

Herpes zoster

Gastritis

AetiologyThe common aetiologies of chest pain in the primary care setting aremusculoskeletal (36%), gastrointestinal (19%), stable angina (10.5%),unstable angina or MI (1.5%), other cardiac (3.8%), psychiatric (8%), andpulmonary (5%). In 16% of cases the cause is not established.[4]

Aetiologies of patients over 35 years of age, admitted to hospital from theemergency department with a chief complaint of non-traumatic chest painare:[5]

acute myocardial infarction (10.7%)

angina/coronary artery disease (22.5%)

atypical chest pain (29.4%)

aortic dissection (0.3%)

other cardiac causes, primarily CHF and atrial fibrillation, (13.8%)

pulmonary embolus (0.4%)

non-PE pulmonary causes, primarily bacterial pneumonia, (11.2%) but also spontaneous

pneumothoraces (0.6%)

abdominal causes (1.6%)

other (10.2%).
http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-4http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-5http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-6http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-10http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-12http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-14http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-15http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-16http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-17http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-19http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-628886http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-5http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-5http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-5http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-4http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-5http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-6http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-10http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-12http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-14http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-15http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-16http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-17http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-19http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-628886http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-5


3/17

Urgent considerationsSee Differential Diagnosis for more details

Acute chest pain warrants rapid clinical assessment, as underlying disease can be life-threatening. Continuous

monitoring of pulse, BP, and oxygen saturation is standard care. If the patient is in pain or breathless, or oxygen

saturation is


4/17

initiated in those patients with PE. D-dimer is helpful in excluding PE.[9] For patients who have a high suspicion

for PE, a transthoracic echocardiogram demonstrating right ventricular hypokinesis and paradoxical septal

motion may indicate acute right ventricular failure from a PE.[9] In patients with shock, systemic thrombolysis,

catheter-directed thrombolysis, or surgical embolectomy should be considered.

Cardiac tamponadeCardiac tamponade may occur suddenly as a result of trauma, aortic dissection, or gradual accumulation of fluid

in the pericardial space. Early recognition and appropriate drainage of pericardial fluid is vital. The condition can

present with muffled heart sounds, distended neck veins, and pulsus paradoxus. Diagnosis is made by

transthoracic echocardiography.

Red flags

Acute coronary syndrome

Pulmonary embolism

Pneumonia

Cardiac tamponade

Aortic dissection

Aortic stenosis


Pneumothorax

Acute cholecystitis

Pancreatitis

Step-by-step diagnostic approachChest pain can be triaged into traumatic and atraumatic aetiologies. The evaluation of atraumatic chest pain

requires an algorithmic approach that first excludes acute myocardial ischaemia before working through the

various aetiologies of chest pain.

History

The character of chest pain should be determined, as this can help differentiate between cardiac, respiratory,

musculoskeletal, and other causes. The type, severity, location, and duration of pain; the presence of any

radiation; and exacerbating or relieving factors may be helpful in pointing towards a diagnosis. Clinical

presentation alone cannot reliably determine acute coronary syndrome (ACS).[10] [11] Past medical history and

specific cardiac risk factors such as known cardiac disease, raised cholesterol, hypertension, smoking, and

family history support a cardiac cause.[12] Cocaine use also makes cardiac ischaemia more likely.[13]A

detailed drug history should also be taken (e.g., use of NSAIDs may result in gastric aetiology).

Certain characteristics of chest pain can give clues to the origin.

Constricting pain may be due to cardiac ischaemia or oesophageal spasm.
http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-1http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-8http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-4http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-5http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-6http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-10http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-16http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-17http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-11http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-11http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-1http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-8http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-4http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-5http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-6http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-10http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-16http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-17http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-11http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-13


5/17

Pain that lasts over 20 minutes and is dull, central, and crushing is likely to be caused by an MI.

Pain that radiates to the jaw or upper extremities suggests a cardiac cause.

Sharp pleuritic pain that catches on inspiration may originate from the pleura or pericardium and

suggests pneumonia, pulmonary embolus, or pericarditis.

A sudden substernal tearing pain that radiates towards the back is the classic presentation of aortic

dissection.

Precipitating and relieving factors can help distinguish between cardiac and gastrointestinal causes (e.g., GORD,

peptic ulcer disease, oesophageal spasm). Pain brought on by food, lying down, hot drinks, or alcohol, and

relieved by antacids suggests a gastrointestinal cause. Cardiac pain is more likely to be brought on by exercise

or emotion and is typically relieved with rest or nitrates. Abdominal pathology such as acute cholecystitis and

pancreatitis may also cause pain referred to the chest. Dyspnoea is an associated symptom in patients with

cardiac ischaemia, PE, pneumothorax, or pneumonia. Nausea, vomiting, and sweating may be seen in patientswith MI.

Physical examination

Physical examination can further narrow down the differential.

Abnormalities revealed in the cardiac examination include abnormalities in pulse or heart sounds (e.g., new

onset of aortic stenosis or worsening of existing murmur), hypo- or hypertension, and signs of heart failure.

Crepitations revealed by auscultation in one or both bases suggest pneumonia or heart failure. Reduced breath

sounds on one side can be caused by a pneumothorax, or focally due to a collapsed lobe.

Tenderness on palpation over the area of chest pain usually indicates a musculoskeletal cause, such as

costochondritis. However, many patients with MI also have chest wall pain on presentation.

A gastrointestinal origin of chest pain is associated with a normal cardiac and respiratory examination, unless

there is existing but stable comorbidity. An abnormal abdominal examination (tenderness, rebound, guarding)

make a gastrointestinal aetiology more likely.

Basic investigations

Basic observations such as temperature, BP, pulse, and respiratory rate should be monitored.

ECG is performed in most patients unless a non-cardiac diagnosis can be made with confidence (e.g.,

pneumothorax). The ECG should be done as soon as possible after presentation. ST changes such as ST

elevation or ST depression, QRS abnormalities, arrhythmias, or tachycardia or bradycardia are characteristic

findings in cardiac causes.View imageView imageView imageView image
http://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/1.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/2.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/4.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/1.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/2.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/4.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/5.html


6/17

CXR can confirm respiratory disorders such as pneumothorax or pneumonia. Cardiac ischaemia is often

characterised by a normal CXR, but a CXR can provide clues to serious cardiac pathology, such as a widened

mediastinum in aortic dissection,View image or a large globular heart in cardiac tamponade.

Blood tests

Cardiac biomarkers (e.g., CK, CK-MB, troponin I and T) found in skeletal and cardiac muscle are raisedin many situations including MI, following a fall or seizure, myositis, hypothermia, or hypothyroidism. CK peaks

approximately 48 hours after the event. CK-MB can be requested if the source of the enzyme needs to be

determined. Troponins peak at 12 to 24 hours after the event and are more sensitive for cardiac damage.

Cardiac biomarkers should be ordered on presentation and at least every 6 to 8 hours after presentation.

An FBC should be ordered to screen for anaemia and evidence of infection.

A renal profile is useful as a baseline test.

Some of the differential diagnoses for chest pain can be excluded or confirmed after history, physical

examination, and basic investigations have been carried out. These include ST-elevation MI (STEMI),

pneumothorax, pneumonia, pericarditis, and costochondritis. The results of the second set of cardiac biomarkers

confirm the diagnosis of non-ST-elevation MI (NSTEMI).

Further investigations

Some differentials need further investigations to confirm the suspected diagnosis.

Coronary angiography is required urgently in patients with a STEMI and in patients with an NSTEMI who have

high-risk features such as ongoing chest pain and dynamic ECG changes.

Once ACS, ventricular arrhythmias, and haemodynamic instability are excluded, patients with chest pain that is

clinically considered to be ischaemic in origin should be stratified by their likelihood of having angina and risk for

MI.

1. Definite angina: patients with a pretest probability of having CAD of >90% should be directly referred for

coronary angiography.

2. Probable angina: patients with a 50% to 90% pretest probability of having CAD may be referred for

stress testing with imaging.

3. Possible angina: patients with a 10% to 50% pretest probability of having CAD should be referred for

either exercise stress testing (EST) or stress testing with imaging.

4. Non-anginal symptoms with a pretest probability of


7/17

Transthoracic echocardiography is a non-invasive way of assessing cardiac function. It is necessary if cardiac

tamponade is suspected and is helpful in confirming a diagnosis of pulmonary hypertension. For a diagnosis of

aortic dissection to be made, transoesophageal echocardiography is more useful. A CT chest is an alternative if

aortic dissection is suspected.

Depending on local availability, a V/Q scan, CT pulmonary angiogram, or pulmonary angiogram is necessary ifPE is suspected.View image

If a gastric diagnosis is the more likely cause for chest pain, then investigations such as

oesophagogastroduodenoscopy, oesophageal pH monitoring, oesophageal manometry, barium swallow,

and Helicobacter pyloribreath test can be considered. A therapeutic trial of proton-pump inhibitors can relieve

symptoms in patients with GORD.[14] Further blood tests such as liver profile, serum lipase, and ABG analysis

may be necessary if acute cholecystitis or acute pancreatitis is suspected. These diagnoses also require further

imaging such as abdominal ultrasound and abdominal CT (for acute pancreatitis).
http://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/6.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-14http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-14http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-14http://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/6.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-14


8/17

Chest pain assessment algorithm.

NSTEMI: non-ST-elevation MI; STEMI: ST-elevation MICreated by the BMJ Evidence Centre

Differential diagnosisSort by: common/uncommonorcategory

Commonhide allAcute coronary syndrome

see our comprehensive coverage of Overview of acute coronary syndromeHistory Exam 1st test

central chest pressure, squeezing, or

heaviness; radiation to jaw or upper

extremities; associated nausea, vomiting,

dyspnoea, dizziness, weakness; occurs at

rest or accelerating tempo (crescendo); risk

factors: smoking, age (men >45, women >55

examination may be normal;

jugular venous distention, S4

gallop, holosystolic murmur

(mitral regurgitation), bibasilar

rales; hypotensive, tachycardic,

bradycardic, or hypoxic depending

ECG: ST-elevation MI (STEMI):

segment elevation >1 mm in 2

anatomically contiguous leads o

left bundle-branch block; non-ST

elevation MI (NSTEMI) or unstab
http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis/by-category.htmlhttp://bestpractice.bmj.com/best-practice/monograph/152.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis/by-category.htmlhttp://bestpractice.bmj.com/best-practice/monograph/152.html


9/17

years), positive FHx of premature CAD,

hypertension, hyperlipidaemia, diabetes,

stroke, or peripheral arterial disease[6] [7]

on severity of ischaemia[6] [7] angina: non-specific; ST-segme

depression or T-wave inversionM

CXR: normal or signs of heart fa

such as increased alveolar

markingsMore cardiac enzymes: elevated in S

and NSTEMI; not elevated in

unstable anginaMore

Stable angina

see our comprehensive coverage of Chronic stable angina

History Exam 1st test Other tests

known history of coronary artery disease; chest

discomfort on exertion; no change in intensity,

frequency, or duration; associated diaphoresis,

nausea/vomiting, or shortness of breath; risk

factors: smoking, age (men >45, women >55 years),

positive family history of premature CAD,

hypertension, hyperlipidaemia, diabetes, stroke, or

peripheral arterial disease[7]

no specific findings

for CAD, may have

abnormal pulses if

peripheral vascular

disease present

ECG: no acute changes;

may have evidence of

previous infarction, such

as Q waves

CXR: normal or

cardiomegaly

cardiac biomarkers: not

elevated

stre

slo

ele

pos

reg

ven

cor

arte

CT

ste

Pulmonary embolism

see our comprehensive coverage of Pulmonary embolism

History Exam 1st test O

sharp and pleuritic in nature; shortness of breath;

haemoptysis may occur if pulmonary infarction

develops; massive PE results in syncope; risk

factors: history of immobilisation, orthopaedic

procedures, oral contraceptive use, previous PE,

hypercoagulable states, or recent travel over long

distances;[28] unilateral swollen lower leg that isred and painful suggests DVT; use of the modified

Wells criteria can help to screen for risk factors and

clinical features suggesting high probability[29]

tachycardia, loud P2, right-

sided S4 gallop, jugular

venous distention, fever,

right ventricular lift;

massive PE may cause

hypotension[28]

ECG: sinus tachycardia;

presence of S1, Q3, and

T3More

D-dimer: non-specific if

positive; PE excluded if result

negative in patients with low

probability of having a PE

CXR: decreased perfusion in a

segment of pulmonary

vasculature (Westermark sign);

presence of pleural effusion

CT pulmonary
http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/148.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/116.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-29http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/148.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/116.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-29http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html


10/17

angiography:identification of

thrombus in the pulmonary

circulationMore

Pneumonia

see our comprehensive coverage of Overview of pneumonia

History Exam 1st test

productive or dry cough, fever, pleuritic

pain associated with shortness of breath;

may have rigors, myalgias, and arthralgias;

recent history of travel or infectious

exposures[30]

decreased breath sounds, rales, wheezing,

bronchial breath sounds, dullness to

percussion, and increased tactile fremitus

observed with severe consolidation[30]

CXR: pulmonary infiltra

bronchograms, and ple

effusion

Viral pleuritis


prodrome of viral illness (myalgias,

malaise, rhinorrhoea, cough, nasal

congestion, low-grade temperatures);

sick contacts

pleural friction rub with or without low-grade

fever; sometimes reproducible tenderness to

palpation of chest when perichondritis or

pleurodynia accompanies pleuritis

CXR: usually normal but

uncommonly have

effusionMore

GORD

see our comprehensive coverage of Gastro-oesophageal reflux disease


retrosternal burning with eating large

or fatty meals that can be reproduced

with lying supine and relieved by

sitting up; relieved by antacids[33]

no specific

physical

findings

therapeutic trial: relief of

symptoms with short trial of

proton-pump inhibitors

Oesophagogas

inflammation or e

oesophageal pH

indicate reflux di

Costochondritis

see our comprehensive coverage of Costochondritis


focal chest wall pain, may have known precipitating injury; aggravated

by sneezing, coughing, deep inspiration, or twisting of the chest

reproducible pain, especially at the

costochondral junctions

CXR

find

Anxiety or panic disorder

see our comprehensive coverage of Panic disorders


sharp chest pain with anxiety, dizziness or faintness, palpitations, hyperventilation, ECG: normal
http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/1113.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/82.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-33http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-33http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-33http://bestpractice.bmj.com/best-practice/monograph/300.htmlhttp://bestpractice.bmj.com/best-practice/monograph/121.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/1113.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/82.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-33http://bestpractice.bmj.com/best-practice/monograph/300.htmlhttp://bestpractice.bmj.com/best-practice/monograph/121.html


11/17

sweating, trembling or shaking, fear of dying or going insane,

paraesthesiae, chills or hot flushes, breathlessness or choking

sensation

examination otherwise

normal

Uncommonhide allPericarditis

see our comprehensive coverage of Pericarditis

History Exam 1st test Other

usually has viral prodrome; sharp pleuritic

chest discomfort provoked by lying supine

and improved with sitting up; associated dry

cough, fever, myalgias, or arthralgias; history

of possible causes such as radiation exposure,

collagen vascular disease, recent MI, or

uraemia

tachycardia and friction

rub; jugular venous

distention and pulsus

paradoxus indicate effusion

causing tamponade

ECG: diffuse concave-up ST-

elevation, associated PR

depression; changes evolve

over timeMore

Cardiac tamponadesee our comprehensive coverage of Cardiac tamponade


history of underlying cause such as MI, aortic

dissection, or trauma; may present insidiously

as a result of hypothyroidism or pericarditis;

dizziness; dyspnoea; fatigue

hypotension, distended neck veins,

muffled heart sounds; pulsus

paradoxus (a drop of 10 mmHg in

arterial BP on inspiration)

ECG: low-voltage QRS; othe

underlying cause (e.g., ST el

specific ST changes in perica

CXR: globular heart (if large

echocardiography: pericard

of great vessels, atria, and ve

Aortic dissection

see our comprehensive coverage of Aortic dissection

History Exam 1st test O

acute substernal tearing sensation, with radiation

to interscapular region of the back; pain may

migrate with the propagation of the dissection;

stroke, acute MI due to obstruction of aortic

branches; dyspnoea due to acute aortic

regurgitation; hypotension due to cardiac

tamponade; history of hypertension, Marfan's

syndrome, Ehlers-Danlos syndrome, or

syphilis[24] [25]

unequal pulses or BPs in both arms; new

diastolic murmur due to aortic

regurgitation; muffled heart sounds if the

dissection is complicated by cardiac

tamponade; new focal neurological

findings due to involvement of the

carotid or vertebral arteries[24] [25]

CXR: widened

mediastinumMore

Aortic stenosis
http://bestpractice.bmj.com/best-practice/monograph/243.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/459.htmlhttp://bestpractice.bmj.com/best-practice/monograph/445.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/243.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/459.htmlhttp://bestpractice.bmj.com/best-practice/monograph/445.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html


12/17

see our comprehensive coverage of Aortic stenosis


age over 60 years; typical angina; chest pain is

usually progressive;[27]shortness of breath;

syncope (if severe); patients with significant

aortic stenosis and heart failure are at high risk

of cardiogenic shock or sudden death

ejection systolic murmur

that radiates to the neck;

obliteration of S2 indicates

severe stenosis; delayed

upstroke on palpation of

carotid pulse

ECG: voltage criteria for

LVH; enlarged P wave

suggesting left atrial

enlargement


see our comprehensive coverage of Mitral valve prolapse

History Exam 1st test Other tes

usually asymptomatic, but may cause

palpitations, chest pain, dyspnoea,

headache, or fatigue

mid-systolic click and

late systolic murmur at

the apex

ECG: usually normal, may show

atrial fibrillation or other arrhythmias

C

p

e

v

Pneumothorax

see our comprehensive coverage of Pneumothorax


acute, pleuritic chest pain, shortness of breath; primary

spontaneous between ages 20 and 40 years; secondary

spontaneous in patients with COPD; traumatic due to acute

trauma or iatrogenic;[31] shock may occur if rapidly increasing

(tension pneumothorax)

absent breath sounds, increased resonance to

percussion; jugular venous distention, trachea

deviation, and hypotension if tension

pneumothorax (due to compromise of the great

vessels)[31]

Pulmonary hypertension

see our comprehensive coverage of Idiopathic pulmonary arterial hypertension


cardiac-sounding chest pain on

exertion, dyspnoea; symptoms of

right-sided heart failure such as

lower extremity oedema,

abdominal bloating, or ascites;

syncope if severe[32]

accentuated pulmonic component

(P2) to the second heart sound;

palpable P2; right ventricular

heave; lower extremity oedema;

jugular venous distention

ECG: right axis

deviation; RVH or right

atrial enlargement

CXR: la

echoca

right ven

ventricu

effusion

Peptic ulcer disease (PUD)

see our comprehensive coverage of Peptic ulcer disease


gastric ulcers: epigastric pain or burning with

onset 5 to 15 minutes after eating and may last

for several hours; duodenal ulcers: epigastric

pain is relieved by eating and may return 1 to 4

epigastric tenderness; if

significant bleeding is

present there may be

tachycardia,

Oesophagogastroduodenoscopy:ga

duodenal erosions or ulceration
http://bestpractice.bmj.com/best-practice/monograph/325.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-27http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-27http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-27http://bestpractice.bmj.com/best-practice/monograph/321.htmlhttp://bestpractice.bmj.com/best-practice/monograph/504.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/292.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/80.htmlhttp://bestpractice.bmj.com/best-practice/monograph/325.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-27http://bestpractice.bmj.com/best-practice/monograph/321.htmlhttp://bestpractice.bmj.com/best-practice/monograph/504.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/292.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/80.html


13/17

hours postprandially; pain from any ulcer is

relieved by antacid; risk factors: cigarette

smoking, NSAIDs, and chronic alcohol

consumption[34]

hypotension, and

conjunctival pallor[34]

Oesophageal spasm

History Exam 1st test Othcrushing substernal chest pain, associated dysphagia,

pain does not always correlate with swallowing,

dysphagia precipitated by very hot or cold foods,

glyceryl trinitrate can relieve the pain[36]

no specific

findings

barium swallow: corkscrew or

rosary bead appearance on

barium swallow

Acute cholecystitis

see our comprehensive coverage of Cholecystitis


right upper quadrant pain, radiation to

the interscapular area or right shoulder,

associated with nausea and vomiting,

fevers, anorexia often accompanies pain,

signs of peritoneal inflammation such as

abdominal pain with jarring[37]

right upper quadrant tenderness

(Murphy's sign), abdominal rigidity

and guarding if perforation of the

gallbladder, rarely have jaundice early

in the course of cholecystitis[37]

liver function tests: elevated

alkaline phosphatase and gammGT More

FBC: leukocytosis with a left

shiftMore

abdominal

ultrasound:pericholecystic fluid

distended gallbladder, thickened

gallbladder wall, and gallstones

Pancreatitis

see our comprehensive coverage of Acute pancreatitis

History Exam 1st test Other t

epigastric or periumbilical abdominal pain

that radiates to the back; may be severe;

associated nausea and vomiting; history of

alcohol consumption or gallstones[40]

tachycardic, hypotensive, febrile, acute

distress; ecchymosis in the

periumbilical region (Cullen's sign) and

the flank (Grey-Turner sign)

serum

lipase: double the

normal valuesMore

Herpes zoster

see our comprehensive coverage of Herpes zoster infection


unilateral, burning pain in typical vesicular rash on erythematous usually no test
http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/78.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/66.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/23.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/78.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/66.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/23.html


14/17

dermatome distribution that may occur

before appearance of rash and may persist

for >1 month

base, in unilateral distribution of

a dermatome

required:diagnosis is

clinical

Gastritis

see our comprehensive coverage of Gastritis

History Exam 1st testdyspepsia/epigastric discomfort; nausea,

vomiting, loss of appetite; history of

NSAID use or alcohol misuse; history

ofHelicobacter pyloriinfection; history of

previous gastric or abdominal surgery

epigastric gastric discomfort may be

present; may have signs associated with

vitamin B12 deficiency and pernicious

anaemia (e.g., abnormal neurological

examination, presence of cognitive

impairment, angular cheilitis, atrophic

glossitis

Helicobacter pylori urea

breath test: positive in H

pyloriinfection

Email

Print

FeedbackShare

Add to Portfolio

Bookmark

Add notes

ST changes associated with ischaemia

Courtesy of Dr Francis Morris
http://bestpractice.bmj.com/best-practice/monograph/816.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/301/resources/images/print/1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/feedback/301/resources/images/print/1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/share/301/resources/images/print/1-2-4-5-6-7.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Chest+pain+(Assessment+of)+-+resources.images.print&dataValue=%2Fbest-practice%2Fmonograph%2F301%2Fresources%2Fimages%2Fprint%2F1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/monograph/816.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/301/resources/images/print/1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/feedback/301/resources/images/print/1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/share/301/resources/images/print/1-2-4-5-6-7.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Chest+pain+(Assessment+of)+-+resources.images.print&dataValue=%2Fbest-practice%2Fmonograph%2F301%2Fresources%2Fimages%2Fprint%2F1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/1-2-4-5-6-7.html


15/17

T-wave changes with ischaemia

Courtesy of Dr Channer

ECG showing changes of an acute inferior MI with ST elevation in leads II, III and aVF


16/17

Used with permission from Professor James Brown

ECG showing diffuse concave upwards ST elevation with associated PR depression suggestive of pericarditis


Spiral CT pulmonary angiogram showing a large filling defect within the pulmonary vasculature compatible with a

saddle embolus



17/17

CXR showing a widened mediastinum


1

bol u grud uvod

Documents