Chest pain and weight loss

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

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell); Coronary CT angiography (CCTA); multidetector row scanners (MDCT); Cardiovascular magnetic resonance — CMRI; Myocardial perfusion imaging (MPI); single-photon emission CT (SPECT); Positron emission tomography (PET) scanning; Magnetic resonance (MR) angiography, Computed tomographic (CT) angiography, and Transesophageal echocardiography (TEE), late gadolinium enhancement (LGE); right ventricular hypertrophy (RVH), right atrial enlargement (RAE), functional tricuspid regurgitation (TR), Pulmonary artery systolic pressure (PASP; adenosine deaminase (ADA); Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL2R); High-resolution CT (HRCT) scanning

Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Cardiac Heart Failure[1][2][3] Subacute or chronic Variable
  • Dull
  • Left sided chest pain
+ +/- + + Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
Pulmonary Pneumonia[4][5][6] Acute or chronic Variable
  • Dull
  • Localized to side of lesion
+ + + +/-
  • Long hospital stay
  • Ill contact exposure
  • Aspiration
Pleural Effusion[7][8][9] Acute or subacute or chronic Variable + +/- + +/-
  • Typically not indicated
Asthma & COPD[10][11][12][13] Acute or subacute or chronic Variable
  • Tightness
+ +/- + +/-
Pulmonary Malignancy[14][15][16][17] Chronic Variable
  • Dull aching
+ +/- + +
  • EKG may be performed before cancer treatment to identify any pre-existing conditions, or during treatment to check for possible heart damage
Sarcoidosis[18][19][20][21] Chronic Days to week
  • Chest fullness
+ - + +
  • Diminished respiratory sounds
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Gastrointestinal GERD, Peptic Ulcer[22][23][24] Acute +/- - - +/-
  • Not any auscultatory findings associated with this disease
  • Enamel erosion or other dental manifestations
Diffuse Esophageal Spasm[25][26][27][28] Acute
  • Minutes to hours
  • 5 to 60 minutes
+ - +/- +/- --- ---
  • Barium swallow: Multiple areas of spasm throughout the length of the esophagus
  • Impedance testing: Higher amplitudes and better transit of swallowed boluses
  • No ECG findings associated with DES, but ECG is done to exclude variant angina due to higher concurrent association of variant angina with DES 
  • Esophageal manometry : ≥20 percent premature contractions (distal latency <4.5 seconds)
Esophagitis[29][30][31] Acute Variable + + - +/-
  • No auscultatory finding
Pancreatitis[32][33][34][35][36] Acute, Chronic Variable - + + +/-
  • Alcohol abuse
  • Smoking
  • Genetic predisposition
  •  Tachypnea
  • Hypoxemia
  • Hypotension
  • Cullen's sign
  • Grey Turner sign 
  • T-wave inversion
  • ST-segment depression
  •  ST-segment elevation rarely
  • Q-waves
  • CT: focal or diffuse enlargement of the pancreas
  • MRI: Pancreatic enlargement
  • CT Scan
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab workup EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Rheumatic Rheumatoid arthritis[37] Chronic Years Symmetrical joint pain in
  • Wrist
  • Fingers
  • Knees
  • Feet
  • Ankles
- + - +
  • Old age
  • Smoking
  • Autoimmune conditions
  • Positive Rheumatic Factor
  • Anti-CCP body 
  • Synovial fluid analysis: WBC between 1500 and 25,000/cubicmm, low glucose, low C3 and C4 complement level.
  • Thrombocytosis
  • Anemia
  • Mild leukocytosis
  • ECG is done rule out the heart failure as RA is one of the causes of heart failure
  • Plain film radiography: periarticular osteopenia, joint space narrowing, and bone erosions
  • MRI: Bone erosions
  • Ultrasonography: Degree of inflammation and the volume of inflamed tissue
---
Systemic lupus erythematosus[38] [39][40] Chronic Years
  • Skin
  • Joints (fingers, wrist, knees)
  • Kidneys
  • SLE can affect any organ of the body
- + + +
  • HLA-genetic mutations
  • Female gender
  • Being younger than 50 
  • Autoimmune conditions
  • Genetic predisposition
  • Positive family history
  • Related to specific organ involvent
  • Anti-dsDNA antibody test
Relapsing polychondritis[41] Chronic Years Intermittent pain in: + + + +
  • Autoimmune diseases
  • Negative rheumatoid factor
  • Anti-type II collagen antibodies
  • Antineutrophil cytoplasmic antibodies
  • ECG is done to rule out the cardiovascular complications of this disease
  • Non specific
  • Related to specific organ involvent
  • No gold standard test for this disease

Others

Substance abuse

(Cocaine)[42][43][44]

Acute (hours) Minutes to hours Pressure like pain in the center of chest + + + +
  • Psychiatric disorders
    • QT prolongation
    • Sinus Tachycardia
    • Arrhythmias
    • Cardiac conduction abnormalities
---
  • Gold standard test depends on the type of substance is abuse

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