chest pain

4/4/2015 Ovid:DifferentialDiagnosisinPrimaryCare

http://ovidsp.tx.ovid.com.ucsf.idm.oclc.org/sp3.15.1b/ovidweb.cgi 1/3

Authors: Collins, R. DouglasTitle: Differential Diagnosis in Primary Care, 4th Edition

Copyright 2008 Lippincott Williams & Wilkins

> Table of Contents > C > Chest Pain

Chest Pain

Hardly a day goes by in a busy practitioner's office that he or she is not confronted with a patient complaining of chest pain. The main concern, of course, is to exclude an acutemyocardial infarction, which is not an easy task in many cases. The practitioner frequently admits the patient for observation, which is the safe thing to do when there is any doubt.With a list of virtually all the diagnostic possibilities in mind, however, fewer patients will require admission for observation. Anatomy forms the basis for formulating such a list.



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Chest pain

Visualizing the organs of the chest and crossindexing them with the various etiologies (Table 14), one finds that at least 30 or 40 conditions must be considered. Proceeding from thesuperficial to the deep structures, one encounters the skin, considers herpes zoster, and looks for a rash. Next, there is muscle; trichinosis, dermatomyositis, and contusion of themuscle must be considered. Coughinduced contusions should not be forgotten. In the same layer, the ribs and cartilage remind one of rib fractures, Tietze syndrome, metastaticcarcinoma, and multiple myeloma. Other rarer conditions of the rib are shown in Table 14.

Many causes of chest pain arise from the pleura. Pneumonia with pleurisy, empyema, pulmonary infarction, and neoplasms of the pleura must be considered. Tuberculous pleurisyand other infectious agents are not

uncommon. In contrast, 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.

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 andchronic coronary insufficiency are common causes of chest pain arising from the myocardium. Myocarditis (e.g., viral) causes less severe pain, but inflammation of the myocardiumfrom 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 orHodgkin lymphoma (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 in Table 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 syndromemay 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 herniateddiscs of the cervical spine: Neurocirculatory asthenia is associated with atypical chest pain; a psychiatric evaluation will assist in this diagnosis.

Approach to the DiagnosisA possible myocardial infarction must be the first consideration in all adults with acute chest pain, especially if there are significant alterations of the vital signs. Consequently, serialECGs, serial cardiac enzymes, and hospitalization will often be necessary. After this condition has been excluded, we can turn our attention to the other possibilities. Arterial bloodgases, chest xray, and a lung scan may be ordered to exclude a pulmonary embolism. Pulmonary angiography may be necessary in some cases. A chest xray may be ordered to ruleout 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 withnitroglycerin under the tongue or by spray will support the diagnosis of coronary insufficiency. Tenderness of the costochondral junctions with relief on lidocaine injection into thepoint 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 outcoronary insufficiency or myocardial infarction. It may be wise to do immediate coronary angiography if the condition deteriorates so that balloon angiography, bypass surgery, orreperfusion therapy may be initiated. Dissecting aneurysm is revealed by CT scan or MRI of the chest.

Other Useful Tests1. CBC

2. Sedimentation rate (pneumonia, infarction)

3. Sputum smear and culture (pneumonia)

4. Bernstein test (reflux esophagitis)

5. Serum cardiac troponin levels (myocardial infarction)

6. DDimer testing (pulmonary embolism)

7. Esophagoscopy (reflux esophagitis)

8. Xray of the spine (radiculopathy)

9. Echocardiogram (pericarditis)

10. 24Hour Holter monitoring (coronary insufficiency)

11. Gallbladder sonogram

12. Ambulatory pH monitoring (esophagitis)

13. Helical CT scan (pulmonary embolism)

14. Single Photon Emission Computed Tomography (SPECT) scan (coronary insufficiency)

CasePresentation#9A58yearoldwhitemaleexecutivewasbroughttotheemergencyroomatmidnightcomplainingofseveresubsternalchestpainof2hoursduration.Question#1.Utilizingthemethodsoutlinedabove,whatisyourlistofpossiblediagnosesatthispoint?Additionalhistoryrevealsthatthepatienthashadseveralpreviousattacksofasimilarnatureoverthepast10years,butneverlastingthislong.Thepaindoesnotradiatetotheneckordownthearm,andisnotaccompaniedbydiaphoresis.Thepainisoftenrelievedbyantacidsbutisincreasedbydeepbreathing.Thereisnohistoryofalcoholintake.Physicalexamination,ECGandlaboratorystudiesareunremarkable.ViewAnswer

Question#2.Whatarethepossiblediagnosestoconsideratthispoint?ViewAnswer

TABLE 14. Chest Pain



V I N D I C A T

Vascular Inflammatory Neoplasm Degenerative andDeficiency

IntoxicationIdiopathic

Congenital Autoimmune Allergic Trauma Endocrine

Skin Herpes zoster

Muscles EpidemicpleurodyniaTrichinosisDiaphragmaticabscess

Intercostalneuralgia

Dermatomyositis ContusionCoughinducedhemorrhage intomuscle

Ribs andCartilages

OsteomyelitisTietzesyndrome

MetastaticcarcinomaMultiplemyelomasarcoma

Osteitisdeformans

Fracture contusion Osteitisfibrosacystica

Pleura Pulmonaryinfarction

PleurisyTuberculosisFungusEmpyema

MetastaticcarcinomaMesenthelioma

Lung Pneumonia Carcinoma(primary andmetastatic)

Pneumothorax Pneumothorax

Pericardium ViralpericarditisRheumaticfeverTuberculosis

Metastaticcarcinoma

Uremia

Myocardium MyocardialinfarctCoronaryinsufficiency

Myocarditis Postinfarctionsyndrome

PostcommissurotomysyndromeContusion

Aorta Aneurysm Aortitis Medionecrosis Ruptured aorta

Esophagus UlcerEsophagitis

Esophagealcarcinoma

Lyeerosion,e.g.

DiverticulumHiatalhernia

Ruptured esophagus

Mediastinum Mediastinitis Dermoid cystHodgkinlymphoma

Substernalthyroiditis

ThoracicVertebrae

OsteomyelitisPott disease

Metastaticcarcinoma

OsteoporosisOsteoarthritis

Rheumatoidspondylitis

FractureHerniated disc

OsteoporosisOsteomalacia

Spinal Cord SyphilisTuberculosisNeuralgia

Tumor Transversemyelitis

Hematomyelia

chest pain

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