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CHEST PAIN

CHEST PAIN. Liu Zhenhua. GENERAL INFORMATION. 50 year-old, Male Bank executive CHIEF COMPLAINT: CHEST PAIN. HISTORY OF PRESENT ILLNESS. (+) HPN for 5 years : highest BP= 180/100 mmHg ; usual BP= 140-150/90 mmHg Irregular intake of amlodipine 5 mg.

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CHEST PAIN

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  1. CHEST PAIN Liu Zhenhua

  2. GENERAL INFORMATION • 50 year-old, Male • Bank executive CHIEF COMPLAINT: CHEST PAIN

  3. HISTORY OF PRESENT ILLNESS (+) HPN for 5 years: highest BP= 180/100 mmHg; usual BP= 140-150/90 mmHg Irregularintake of amlodipine 5 mg • intermittent non radiating substernal chest heaviness precipitated after climbing 2 flight of stairs • Grade 3/10 • Relieved after 5 minutes rest • Recurring 1x a month 1 year ago • same character of chest pain, recurring every week, precipitated after climbing only one flight of stairs lasting 10-15 minutes relieved by rest • Recurring 1x 2 weeks 6 months ago • chest heaviness recurring everyday (grade 6/10) 20-30 minutes duration • Precipitated after walking only 5 to 10 meters relieved by rest 1 week ago Consultation and subsequent admission

  4. SALIENT FEATURES • Subjective • 50 year old , Male • Bank executive • Hypertensive for 5 years • Progressive substernal chest pain, recurring everyday, grade 6/10 lasting for 20-30 minutes precipitated after walking only • 5-10m • Non-compliance to medication • Family history of hypertension, diabetes mellitus and heart problems • Fond of eating steak and bulalo • No regular exercise • smoker- 20 pack years • Alcohol intake • Objective • BP 170/100 • PR 100 per minute • BMI= 31 (obese)

  5. CHIEF COMPLAINT:CHEST PAIN An unpleasant sensation in the anterior wall of the thorax associated with actual or potential tissue damage and mediated by specific nerve fiber to the brain where conscious appreciation may be modified by various factors Source: Stedman’s Medical Dictionary 27th Edition

  6. Introduction • Patients with acute nontraumatic chest pain present a diagnostic challenge • May appear very ill or completely well • Significant risk for sudden death or AMI • Initial assessment should focus on stability • Consider the 6 structures in the chest

  7. Differential Diagnosis of Chest Pain • Heart: Acute coronary syndrome (ACS), pericarditis, myocarditis, valvular diseases (especially aortic stenosis) • Lungs: pneumonia/other infections, pneumothorax, Pulmonary embolism (PE), COPD • Esophagus: esophagitis, GERD, spasm, foreign body, carcinoma • Aorta: dissection, aneurysm, aortitis • Upper Abdomen: cholecystitis, pancreatitis, ulcer, hepatic disease • Chest wall: shingles,costochondritis, contusion, rib fracture, muscle strain or tear

  8. Causes Cardiovascular Pulmonary Gastrointestinal Musculoskeletal Neurological

  9. CARDIOVASCULAR • progressive non radiating chest heaviness • usually occurring for 10-30 minutes • Initially, precipitated by climbing the stairs • lately precipitated by walking 5-10 meters Source: Bates’ A Guide to Physical Examination and History Taking, 6th edition

  10. Chest Pain Cardiovascular Respiratory Gastrointestinal Musculoskeletal Neurological

  11. RESPIRATORY

  12. Pleuritis - inflammation or irritation of the pleural membrane; often caused by infection, pulmonary embolism, pneumothorax, arthritis, lupus, or cancer, manifests as a sharp pain when breathing, coughing, or sneezing Pneumonia – fever, chills, productive cough Pneumonia or lung abcess –causes deep chest ache and possibly pleuritic pain Pulmonary Embolism – a dislodged thrombus travels through the bloodstream into the lungs; likely follows deep vein thrombosis Pneumothorax – lung collapse, often caused by injury to the chest, resulting in release of air into thoracic cavity Pulmonary Hypertension – abnormally high blood pressure in the arteries of the lungs, forcing the right side of the heart to work too hard Asthma – inflammation of the airways, causing wheezing, shortness of breath, coughing, chest pain

  13. RESPIRATORY There is specific duration (usually 10-30 minutes No cough or dyspnea and is relieved with rest • No sharp, burning pain (chest heaviness) Source: Bates’ A Guide to Physical Examination and History Taking, 6th edition

  14. Chest Pain Cardiovascular Respiratory Gastrointestinal Musculoskeletal Neurological

  15. GASTROINTESTINAL

  16. Gastroesophageal reflux disease (GERD) – similar to angina because esophagus and heart are located close to each other and they share a nerve network • Others • Esophageal Contraction Disorders • Esophageal Hypersensitivity • Esophageal Carcinoma • Esophageal Rupture • Hiatal Hernia – stomach herniates into the diaphragm • Pancreatitis • Lung abcess • Gallbladder problems

  17. GASTROINTESTINAL no squeezing pain (chest heaviness) There is specific duration (usually 10-30 minutes) not aggravated by food intake, relieved by rest Source: Bates’ A Guide to Physical Examination and History Taking, 6th edition

  18. Chest Pain Cardiovascular Respiratory Gastrointestinal Musculoskeletal Neurological

  19. Musculoskeletal no stabbing, dull, localized pain (chest heaviness) there is specific duration (usually 10-30 minutes) not aggravated by twisting upper body, and relieved with rest • Cause by: • Bone Pain – ribs or sternum may be fractured • Muscle Strain – may be caused by excessive coughing Source: Bates’ A Guide to Physical Examination and History Taking, 6th edition

  20. Chest Pain Cardiovascular Respiratory Gastrointestinal Musculoskeletal Neurological

  21. Neurological • no visceral tightness, precordial, L breast pain (chest heaviness) • usually occurs < 30 minutes • not aggravated by emotional stress Neurological Shingles – caused by varicella zoster virus; causes nerve pain in chest area Psychological Anxiety or panic attacks Source: Bates’ A Guide to Physical Examination and History Taking, 6th edition

  22. Chest Pain Cardiovascular Respiratory Gastrointestinal Musculoskeletal Neurological

  23. References: Mosby’s Guide to Physical Examination, 6th edition. Harrison’s Principles of Internal Medicine 17th edition

  24. Typically caused by exertion or emotion Crescendo-decrescendo in nature, 2-5 mins, radiates **Levine’s sign - when the patient is asked to localize pain, he or she will typically press on the sternum sometimes with a clenched fist, to indicate a squeezing, central, substernal discomfort Radiates to L shoulder especially to the ulnar surfaces of the forearm and hand. May also radiate to the back, interscapular region, root of the neck, jaw, teeth and epigastrium

  25. Differential Diagnosis of Chest Pain • Heart: ACS, pericarditis, myocarditis, valvular diseases (especially aortic stenosis) • Lungs: pneumonia/other infections, pneumothorax, PE, COPD • Esophagus: esophagitis, GERD, spasm, foreign body, carcinoma • Aorta: dissection, aneurysm, aortitis • Upper Abdomen: cholecystitis, pancreatitis, ulcer, hepatic disease • Chest wall: shingles,costochondritis, contusion, rib fracture, muscle strain or tear

  26. Thank You !

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