chest pain - differencial diognosis

8/14/2019 Chest Pain - Differencial Diognosis

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Pulmonary

1. Pleuritic chest pain2. Pneumonia

3. Pulmonary embolism4. Pulmonary hypertension5. Spontaneous pneumothorax

Gastrointestinal

1. Reflux esophagitis2. Esophageal spasm/angina3. Peptic ulcer

4. Pancreatitis5. Cholecystitis

Musculoskeletal disorders

1. Costochondritis2. Tietzes syndrome3. Rib fracture or trauma4. Cancer metastsis5. Sternoclavicular arthritis

6. Painful xiphoid syndrome7. Fibromyalgia8. Traumatic muscle pain

9. Shoulder arthritis/bursitis10. Cervicothoracic nerve root compression11. Thoracic spine arthritis

12. Throracic outlet syndrome

Miscellaneous

1. Herpes zoster2. Anxiety/depressive disorder

3. Panic disorder4. Cocaine use5. Post coronary artery bypass pain

Many causes of chest pain arise from the pleura. Pneumonia with pleurisy, empyema, pulmonary infarction, and

neoplasms of the pleura must be considered. Tuberculous pleurisy and other infectious agents are not uncommon. On

the other hand, conditions of the lung are less likely to cause chest pain unless they involve the pleura: This is certainly

true of pneumonia and neoplasms. A pneumothorax, however, is a very common cause of chest pain, especially in

young adults.

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Visualize the heart and the pericardium comes to mind. This is a source of chest pain in acute idiopathic pericarditis,

rheumatic carditis, and tuberculous and neoplastic pericarditis. The myocardium is the source of the most serious form

of chest pain, myocardial infarction, but here again the pain is more severe if the pericardium is involved. Angina

pectoris and chronic coronary insufficiency are common causes of chest pain arising from the myocardium. Myocarditis

(e.g., viral) causes less severe pain, but inflammation of the myocardium from postinfarction syndrome or

postpericardiotomy syndrome can be extremely painful.

Now visualize the other central structures: The esophagus reminds one of reflux esophagitis and hiatal hernia, the

mediastinum suggests mediastinitis and substernal thyroiditis or Hodgkin disease (usually not too painful), the aorta

suggests dissecting aneurysms, and the thoracic spine suggests spinal cord tumors, osteoarthritis, Pott disease,

fractures, herniated discs, as well as the other conditions listed inTable 14.

This chapter would not be complete unless referred pain to the chest was considered. Thus, abdominal conditions such

as cholecystitis, pancreatitis, and splenic flexure syndrome may present with chest pain. Conditions of the neck that

press the cervical nerves may also cause chest pain, particularly scalenus anticus syndrome, cervical ribs, and

herniated discs of the cervical spine:

Neurocirculatory asthenia is associated with atypical chest pain; a psychiatric evaluation will assist in this diagnosis.

Approach to the Diagnosis

A possible myocardial infarction must be the first consideration in all adults with acute chest pain especially if there aresignificant alterations of the vital signs. Consequently, serial ECGs, serial cardiac enzymes, and hospitalization will often

be necessary. Once this condition has been excluded, we can turn our attention to the other possibilities. Arterial blood

gases, chest x-ray, and a lung scan may be ordered to exclude a pulmonary embolism. Pulmonary angiography may be

necessary in some cases. A chest x-ray may be ordered to rule out pneumonia. Acute chest pain related to esophagitis

is often relieved by swallowing lidocaine viscus, an extremely useful tool in the differential diagnosis. Relief of the pain

with nitroglycerin under the tongue or by spray will support the diagnosis of coronary insufficiency. Tenderness of the

costochondral junctions with relief on lidocaine injection into the point of maximum tenderness suggests Tietze

syndrome (costochondritis). In cases of chronic chest pain, an exercise tolerance test with thallium scan should be done

to rule out coronary insufficiency or myocardial infarct. It may be wise to do immediate coronary angiography if the

condition deteriorates so that balloon angiography, bypass surgery, or reperfusion therapy may be initiated. Dissecting

aneurysm is revealed by CT scan or MRI of the chest.

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Myocardial infarction

Crushing substernal pain radiating to left arm, shoulder blades, and neck; feeling of impending doom; nausea; shortness

of breath; sweating; ST-segment changes on electrocardiogram; elevated serum CK-MB and troponin-I levels

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Other Useful Tests

1. CBC

2. Sedimentation rate (pneumonia, infarction)

3. Sputum smear and culture (pneumonia)

4. Bernstein test (reflux esophagitis)5. Serum cardiac troponin levels [myocardial infarction (MI)]

6. d-Dimer testing (pulmonary embolism)

7. Esophagoscopy (reflux esophagitis)

8. X-ray of the spine (radiculopathy)

9. Echocardiogram (pericarditis)

10. 24-hour Holter monitoring (coronary insufficiency)

11. Gallbladder sonogram

12. Ambulatory pH monitoring (esophagitis)

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chest pain - differencial diognosis

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