Chest pain differential diagnosis: Difference between revisions

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===Clinical Features of Different Conditions Presenting with  Chest Discomfort===
===Clinical Features of Different Conditions Presenting with  Chest Discomfort===
====CARDIOVASCULAR====
{| class="sortable" border="1" cellpadding="5" cellspacing="0" align="center" style="text-align:center;"
|-
  ! Condition
  ! Onset
  ! Duration
  ! Type of pain
  ! Location
  ! Exacerbating factors
  ! Alleviating factors
  ! Radiation
  ! Associated features
  ! Diagnostic Tests
|-
  |'''[[Stable Angina]]'''
  |Sudden (acute)
  |2-10 minutes
  |Heaviness, pressure, tightness, squeezing, burning ([[Levine's sign]])
  |Retrosternal
or left sided chest pain
  |Exertion, emotions, cold, stress
  |Rest, sublingual nitroglycerine (within minutes)
  |Radiation to neck, jaw, shoulders, or arms (commonly on left)
  |dyspnea, nausea and vomiting, diaphoresis, presyncope, or palpitations
  |
|-
  |'''[[Unstable Angina]]'''
  |Acute
  |10-20 minutes
  |Same as stable angina but often more severe
  |Retrosternal
or left sided chest pain
  |Same as stable angina but occurs with lower levels of exertion & rest
  |May or may not relieved by nitroglycerine and rest
  |Same as stable angina
  |Same as stable angina
  |
|-
  |'''[[Myocardial Infarction]]'''
  |Acute
  |Commonly > 20 minutes
  |Same as stable angina but often more severe
  |Retrosternal
or left sided chest pain
  |Same as stable angina but occurs with lower levels of exertion & rest
  |Usually not relieved by nitroglycerine and rest
  |Same as stable angina
  |Same as stable angina
  |Elevated cardiac enzymes
|-
  |'''[[Aortic Stenosis]]'''
  |Acute, recurrent episodes of angina
  |2-10 minutes
  |Same as stable angina
  |Retrosternal
  |Same as stable angina
  |Same as stable angina
  |Same as stable angina
  |Not specific
  |
|-
  |'''[[Aortic Dissection]]'''
  |Sudden severe progressive pain (common) or chronic (rare)
  |Variable
  |Tearing, ripping sensation, knife like
  |Depends on area of dissection
  |Variable
  |Unrelenting pain, unrelieved by nitroglycerine and rest
  |Radiating to back, between shoulder blades (dissection in ascending aorta)
  |
* Pulse deficit
* New diastolic murmur
* Hypotension
  |blood pressure (>20 mmHg difference between the right and left arm,
CXR: Mediastinal and/or aortic widening
CTA
MRA
TEE
|-
  |'''[[Pericarditis]]'''
  |Acute or subacute
  |May last for hours to days
  |Sharp, localized
  |Retrosternal
  |Increases with coughing, deep breathing, supine position
  |Relieved by sitting up and leaning forward
  |Radiation to shoulder, neck, back abdomen
  |Pericardial friction rub
  |EKG changes (typically widespread ST segment elevation)
|-
|[[Pericardial Tamponade]]
|Acute or subacute
|May last for hours to days
|Sharp and stabbing
|Retrosternal
|Worsens with deep breathing or coughing
|Relieved by sitting upright or leaning forward
|
|Kussmaul sign
Peripheral edema
* Beck triad
* Pulsus paradoxus
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* EKG findings: Sinus tachycardia, low QRS voltage, and electrical alternans
|-
|[[Heart Failure]]
|Subacute or chronic
|Variable
|Dull
|Left sided chest pain
|Worsens on exertion
|Non specific
|Non radiating
|Dyspnea
Orthopnea
Peripheral edema
Hemoptysis
|S3
Elevated JVP
|-
|[[Stress cardiomyopathy|Stress (takotsubo)]]
[[Stress cardiomyopathy|Cardiomyopathy]]
|Acute
|Commonly > 20 minutes
|Heaviness, tightness
|Substernal 
|Worsens with stress
|No relieving factors
|Non radiating
|Setting of physical or emotional stress or critical illness
Dyspnea
|Catecholamines transiently elevated,
[[ST elevation]] in [[precordial leads]], [[LV]] regional dysfunction
|-
|}
====PULMONARY====
{| class="sortable" border="1" cellpadding="5" cellspacing="0" align="center" style="text-align:center;"
|-
  ! Condition
  ! Onset
  ! Duration
  ! Type of pain
  ! Location
  ! Exacerbating factors
  ! Alleviating factors
  ! Radiation
  ! Associated features
  ! Diagnostic Tests
|-
  |'''[[Pulmonary Embolism]]'''
  |Acute
  |May last minutes to hours
  |Sharp, or knifelike pleuritic pain
  |Localized to side of lesion
  |Increased on respiratory movements, deep breathing or cough
  |Not specific
  |Not specific
  |[[Dyspnea]], [[tachypnea]], [[palpitation]], and [[light headedness]], hemoptysis, or a history of venous thromboembolism or coagulation abnormalities.
  |
|-
  |'''[[Pneumothorax|Spontaneous Pneumothorax]]'''
  |Acute
  |May last minutes to hours
  |Sharp, localized pleuritic
  |Localized to side of lesion
  |Not specific
  |Not specific
  |Not specific
  |Dyspnea, decreased breath sounds on involved side
  |
|-
|[[Tension Pneumothorax]]
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|[[Pneumonia]]
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|[[Tracheitis]]/ [[Bronchitis]]
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  |'''[[Pleuritis]]'''
  |Acute, subacute, chronic
  |May last minutes to hours
  |Sharp, localized pleuritic
  |Localized to side of lesion
  |Increased on respiratory movements, deep breathing or cough
  |Not specific
  |Not specific
  |Dyspnea, cough, fever
  |
|-
  |'''[[Pulmonary Hypertension]]'''
  |Acute, subacute, chronic
  |Variable
  |Pressure like
  |Substernal
  |Not specific
  |Not specific
  |Not specific
  |Dyspnea, symptoms of [[right heart failure]] ([[edema]]
  |
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|[[Pleural Effusion]]
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|[[Asthma]] & [[COPD]]
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|[[Lung Cancer|Pulmonary Malignancy]]
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|[[Sarcoidosis]]
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|[[Acute chest syndrome]]
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|}
====GASTROINTESTINAL====
{| class="sortable" border="1" cellpadding="5" cellspacing="0" align="center" style="text-align:center;"
|-
  ! Condition
  ! Onset
  ! Duration
  ! Type of pain
  ! Location
  ! Exacerbating factors
  ! Alleviating factors
  ! Radiation
  ! Associated features
  ! Diagnostic Tests
|-
  |'''[[GERD]], [[Peptic Ulcer]]'''
  |Acute
  |Minutes to hours (gastroesophageal reflux), prolonged (peptic ulcer)
  |Burning
  |Substernal, epigastric
  |Increases on alcohol, aspirin, post meal lying down, morning, empty stomach
  |Relieves on antacid, food
  |Not specific
  |Not specific
  |
  |
|-
  |'''Esophageal Spasm'''
  |Acute
  |Minutes to hours
  |Burning, pressure
  |Retrosternal
  |Not specific
  |Relieved by sublingual nitroglycerine
  |Not specific
  |Not specific (closely mimic angina)
  |
|-
|[[Esophagitis]]
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|[[Eosinophilic esophagitis|Eosinophilic Esophagitis]]
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|[[Esophageal perforation|Esophageal Perforation]]
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|[[Mediastinitis]]
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  |'''[[Gallstone disease| Cholelithiasis]]'''
  |Acute, subacute
  |Minutes to hours
  |Burning, colicky
  |Right upper abdomen, substernal, epigastric
  |Increases post meal, fatty food, 1-2 hours post meal
  |Analgesics
  |Not specific
  |Not specific
  |
|-
|[[Pancreatitis]]
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|[[Hiatal Hernia|Sliding Hiatal Hernia]]
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|}
====MUSCULOSKELETAL ====
{| class="sortable" border="1" cellpadding="5" cellspacing="0" align="center" style="text-align:center;"
|-
  ! Condition
  ! Onset
  ! Duration
  ! Type of pain
  ! Location
  ! Exacerbating factors
  ! Alleviating factors
  ! Radiation
  ! Associated features
  ! Diagnostic Tests
|-
  |'''[[Muscular pain|Musculo-skeletal Pain]]'''
  |Acute, subacute
  |Variable
  |Pressure, aching
  |Localized to involved area
  |Increases by movement and pressure on involved area
  |Analgesics
  |Not specific
  |Not specific
  |
|-
|Rib pain
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|[[Chest pain differential diagnosis#Isolated musculoskeletal chest pain syndromes:|Isolated musculoskeletal chest pain syndromes]]
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|[[Chest pain differential diagnosis#Rheumatic diseases|Rheumatic diseases]]
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|Traumatic
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====PSYCHIATRIC ====
{| class="sortable" border="1" cellpadding="5" cellspacing="0" align="center" style="text-align:center;"
|-
  ! Condition
  ! Onset
  ! Duration
  ! Type of pain
  ! Location
  ! Exacerbating factors
  ! Alleviating factors
  ! Radiation
  ! Associated features
  ! Diagnostic Tests
|-
|[[Panic attack]]/ Disorder
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  |'''Other [[Psychotic disorders]]'''
  |Acute, subacute, chronic
  |Variable
  |Variable
  |Variable
  |Variable
  |Not specific
  |Not specific
  |History of depression, Panic attacks, Agrophobia
  |
|-
|}
====OTHER  ====
{| class="sortable" border="1" cellpadding="5" cellspacing="0" align="center" style="text-align:center;"
|-
  ! Condition
  ! Onset
  ! Duration
  ! Type of pain
  ! Location
  ! Exacerbating factors
  ! Alleviating factors
  ! Radiation
  ! Associated features
  ! Diagnostic Tests
|-
|Substance abuse ([[Cocaine abuse|Cocaine]])
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|[[Referred pain]]
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|[[Herpes Zoster]]
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|Domestic abuse
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|[[Stress fracture]]
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|[[Sickle cell disease]]
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|}


=== Isolated musculoskeletal chest pain syndromes: ===
=== Isolated musculoskeletal chest pain syndromes: ===

Revision as of 03:58, 31 January 2018


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]

Chest pain Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Chest pain from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Chest Pain in Pregnancy

Diagnosis

Diagnostic Study of Choice

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X-ray

Echocardiography and Ultrasound

CT scan

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Interventions

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Chest pain differential diagnosis On the Web

Most recent articles

cited articles

Review articles

CME Programs

Powerpoint slides

Images

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US National Guidelines Clearinghouse

NICE Guidance

FDA on Chest pain differential diagnosis

CDC on Chest pain differential diagnosis

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to Hospitals Treating Chest pain differential diagnosis

Risk calculators and risk factors for Chest pain differential diagnosis

An expert algorithm to assist in the diagnosis of Chest pain can be found here

To go back to the main page on Unstable angina, click here

Overview

There are several life-threatening causes of chest pain which need to be evaluated for first, which include; myocardial infarction, aortic dissection, esophageal rupture, pulmonary embolism, and tension pneumothorax. The other possible causes of chest pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history.

Differential Diagnosis

5 Life Threatening Diseases to Exclude Immediately

The frequency of conditions exclusive of acute myocardial infarction in a decreasing order is:[1]

Differentiating the Life Threatening and Ischemic Causes of Chest Pain from other Disorders

Thorough history including: onset, duration, type of pain, location, exacerbating factors, alleviating factors, and radiation. Risk factors for coronary artery disease: family history, smoking, hyperlipidemia, and diabetes.

Clinical Features of Different Conditions Presenting with Chest Discomfort

Isolated musculoskeletal chest pain syndromes:

Condition Onset Duration Type of pain Location Exacerbating factors Alleviating factors Radiation Associated features Diagnostic Tests
Costosternal syndromes (costochondritis)
Lower rib pain syndromes
Sternalis syndrome
Tietze's syndrome
Xiphoidalgia
Spontaneous sternoclavicular subluxation
Posterior chest wall pain syndromes

Rheumatic diseases:

Condition Onset Duration Type of pain Location Exacerbating factors Alleviating factors Radiation Associated features Diagnostic Tests
Fibromyalgia
Rheumatoid arthritis
Ankylosing spondylitis
Psoriatic arthritis
Sternocostoclavicular hyperostosis (SAPHO syndrome)
Systemic lupus erythematosus 
Relapsing polychondritis

References

  1. ↑ Fruergaard P, Launbjerg J, Hesse B, Jørgensen F, Petri A, Eiken P, Aggestrup S, Elsborg L, Mellemgaard K (1996). "The diagnoses of patients admitted with acute chest pain but without myocardial infarction". European Heart Journal. 17 (7): 1028–34. PMID 8809520. Retrieved 2012-05-02. Unknown parameter |month= ignored (help)
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