Diagnosis Wikidoc: Chest Pain no ST elevation
Jump to navigation
Jump to search
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
There are 4 other Life Threatening Diseases to Exclude Immediately:
1. Aortic Dissection
- Supportive symptoms and signs include the following:
- Back pain in 67% of cases
- Diminution or absence of pulses in 40% of case
- Coma, altered mental status, Cerebrovascular accident (CVA) and vagal episodes are seen in up to 20%
- Descending dissection can lead to splanchnic ischemia, renal insufficiency, lower extremity ischemia or pulse deficits or focal neurologic deficits due to spinal cord ischemia.
- Chest X-Ray Abnormalities Include:
- An increased aortic diameter is the most common CXR finding, seen in up to 84% of patients.
- A widened mediastinum is the next most common finding, seen in 15-20%.
- Normal in 17%.
- Pleural effusion (hemothorax) in the absence of CHF can also be another clue to dissection.
- Next Study to Do:
- MRI is currently thought to be the most sensitive noninvasive method of making the diagnosis of aortic dissection. As with CT, the diagnosis is made upon visualization of a double lumen with a visible flap. Sensitivity and specificity are both thought to be 98%, and the site of entry can be visualized in 85% of cases.
2. Pulmonary Embolism
- Supportive symptoms include:
- Shortness of breath
- Chest pain
- Dyspnea
- Anxiety
- Pleuritic chest pain
- Supportive laboratory studies include:
- D-dimers are formed by the degradation of fibrin clot.
- Almost all patients with PE have some endogenous fibrinolysis, and therefore have elevated levels of D-dimer.
- Many other processes, such as pneumonia, congestive heart failure (CHF), myocardial infarction (MI), malignancy, and surgery, are also associated with a mild degree of fibrinolysis, and hence an elevated D-dimer is not specific for pulmonary embolism.
- Its negative predictive value, however, is 91 – 94%
- Next study to do:
- Spiral CT scanning is now a standard modality to non-invasively diagnose PE.
- Initial studies reported sensitivities for diagnosing emboli to the segmental level (4th order branch) as high as 98%
3. Tension Pneumothorax
- Supportive signs and symptoms include"
- Sudden shortness of breath, cyanosis (turning blue) and pain felt in the chest and/or back are the main symptoms.
- In penetrating chest wounds, the sound of air flowing through the puncture hole may indicate pneumothorax, hence the term "sucking" chest wound.
- The flopping sound of the punctured lung is also occasionally heard.
- Spontaneous pneumothoraces are reported in young people with a tall stature. As men are generally taller than women, there is a preponderance among males.
- Pneumothorax can also occur as part of medical procedures, such as the insertion of a central venous catheter (an intravenous catheter) in the subclavian vein or jugular vein. While rare, it is considered a serious complication and needs immediate treatment. Other causes include mechanical ventilation, emphysema and rarely other lung diseases (pneumonia).
4. Esophageal Rupture
- Supportive signs and symptoms include:
- The classic Meckler's triad of symptoms includes vomiting, lower chest pain, and cervical subcutaneous emphysema following overindulgence in food or alcohol, but is observed in only half of the cases.
- The most common chest radiograph findings in spontaneous esophageal rupture (SER) are pleural effusion (91%) and pneumothorax (80%).
- The initial sign on a plain film may be pneumomediastinum or subcutaneous emphysema.
- Up to 12% of patients with SER may have a normal chest radiograph.
- Next study to do:
- Contrast-enhanced esophageal radiography is diagnostic in 75% to 85% of cases.
Other conditions to Consider
Cardiovascular
- Acute Coronary Syndrome
- Angina
- Aortic Aneurysm
- Aortic Stenosis
- Arryhthmias
- Bland-White-Garland Syndrome
- Cardiac tamponade
- Cor pulmonale
- Coronary Heart Disease
- Dressler's syndrome (postpericardiotomy)
- Functional cardiac problems
- Hypertrophic Cardiomyopathy
- Mitral valve prolapse
- Myocarditis
- Pericarditis
Gastrointestinal
- Abdominal distension
- Achalasia
- Carcinoma
- Cholecystitis
- Cholelithiasis
- Diverticula
- Esophageal rupture
- Esophageal spasm
- Esophagitis
- Foreign body
- Gastritis
- Gastroesophageal reflux disease (GERD)
- Hiatus Hernia
- Impacted stone
- Liver abscess
- Mallory-Weiss Syndrome
- Neoplasm
- Pancreatitis
- Peptic ulcer disease
- Perforated ulcer
- Plummer-Vinson Syndrome
- Pneumoperitoneum
- Splenic enlargement
- Splenic infarction
- Subdiaphragmatic abcsess
- Subphrenic abscess
- Whipple's Disease
Musculoskeletal
- Bechterew's Disease
- Bone tumor
- Chest wall injuries
- Costochondritis
- CS/TS osteochondrosis
- Fractured rib
- Herpes Zoster
- Intercostal muscle spasm
- Interstitial fibrosis
- Muscle strain or spasm
- Myostitis
- Periostitis
- Soft tissue tumor
- Strain of pectoralis muscle
- Tietze's Syndrome
- Thoracic Outlet Syndrome
- Trauma
- Vertebrogenic thoracic pain
Pulmonary
- Asthma
- Bronchial carcinoma
- Bronchiectasis
- Bronchogenic carcinoma
- Carcinomatous effusion
- Chronic Obstructive Pulmonary Disease (COPD)
- Empyema
- Hemothorax
- Lung Abscess
- Lung Cancer
- Lymphoma
- Mediastinitis
- Mesothelioma
- Metastatic tumor
- Pleural mesothelioma
- Pleuritis
- Pleurodynia
- Pneumomediastinum
- Pneumonia
- Pneumothorax
- Pulmonary Embolism
- Pulmonary Infarction
- Retropharyngeal abscess
- Tension pneumothorax
- Thymoma
- Tracheoesophageal abscess
- Tuberculosis
Miscellaneous
- Acromegaly
- Anxiety disorders
- Collagen vascular disease with pleuritis
- Conn's Syndrome
- Degenerative changes of cervical spine
- Depression
- Diabetes Mellitus
- Extrasystoles
- Familial Mediterranean Fever
- Hepatitis
- HIV infection
- Hyperkinetic heart syndrome
- Hyperthyroidism
- Hypoglycemia
- Hypothyroidism
- Intercostal neuralgia
- Liver Cancer
- Neurofibroma
- Neurotic
- Panic disorder
- Peritonitis
- Pheochromocytoma attack
- Pott's Disease
- Tabes dorsalis
- Xyphodenia
- Zoster