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Chest pain There are many causes of chest pain, and while many are not serious, it may be difficult to distinguish among heart attack, pulmonary embolus or aortic dissection, and another diagnosis that is not life-threatening. For that reason, patients are routinely advised to seek medical care for most types of chest pain.

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Post on 02-Jul-2015



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  • 1. Chest pain There are many causes of chest pain, and while many are not serious, it may be difficult to distinguish among heart attack, pulmonary embolus or aortic dissection, and another diagnosis that is not life-threatening. For that reason, patients are routinely advised to seek medical care for most types of chest pain.

2. While each cause of chest pain has a classic presentation, there are enough variations that it may take specific testing to come to a diagnosis. These tests will depend on the patient's presentation and the health care professional's index of suspicion as to what the diagnosis might be. 3. Chest pain introduction Chest pain is one of the most common complaints that will bring a patient to the emergency department. Seeking immediate care may be lifesaving, and considerable public education has been undertaken to get patients to access medical care when chest pain strikes. While the patient may be worried about a heart attack, there are many other causes of pain in the chest that the health care professional will need to consider. Some diagnoses are life-threatening, while others are less dangerous. 4. Deciding the cause of chest pain is sometimes very difficult and may require blood tests, X-rays, CT scans and other tests to sort out the diagnosis. Often though, a careful history taken 5. You may feel chest pain anywhere from your neck to your upper abdomen. Depending on its cause, chest pain may be: Sharp Dull Burning Aching Stabbing A tight, squeezing, or crushing sensation 6. What are the sources of chest pain? The following anatomic locations can all be potential sources of chest pain: the chest wall including the ribs, the muscles, and the skin; the back including the spine, the nerves, and the back muscles; the lung, the pleura (the lining of the lung), or the trachea; the heart including the pericardium (the sac that surrounds the heart); 7. the aorta; the esophagus; the diaphragm, the flat muscle that separates the chest and abdominal cavities referred pain from the abdominal cavity including organs like the stomach, gallbladder, and pancreas, as well as irritation from the underside of the diaphragm due to infection, bleeding or other types of fluid. 8. What are the causes of chest pain? Pain can be caused by almost every structure in the chest. Different organs can produce different types of pain but unfortunately the pain is not specific to each cause. 9. Broken or bruised ribs Pleuritis or pleurisy Pneumothorax Shingles Pneumonia Pulmonary embolus Angina Heart attack (myocardial infarction) Pericarditis The aorta and aortic dissection The esophagus and reflux esophagitis Referred abdominal pain 10. How is chest pain diagnosed? The key to diagnosis remains the patient history. Learning about the nature of the pain will give the health care professional direction as to what are reasonable diagnoses to consider, and what are reasonable to exclude. Understanding the quality and quantity of the pain, its associated symptoms and the risk factors for disease, can help the doctor assess the probability of each potential cause and make decisions about what potential diagnoses should be considered and which should be discarded. 11. Duration of pain: Duration of pain can provide clues to the severity of the disorder. Long-standing pain (ie, for weeks or months) is not a manifestation of a disorder that is immediately life threatening. Such pain is often musculoskeletal in origin, although GI origin or a cancer should be considered, particularly in patients who are elderly. Similarly, brief (< 5 sec), sharp, intermittent pains rarely result from serious disorders. Serious disorders typically manifest pain lasting minutes to hours, although episodes may be recurrent (eg, unstable angina may cause several bouts of pain over 1 or more days). 12. Questions the doctor may ask about chest pain When did the pain start? What is the quality of the pain? How long does the pain last? Does the pain come and go? What makes the pain better? What makes the pain worse? Does the pain radiate somewhere (move to another area of the body)? Has there been any preceding illness? Has there been any trauma? Have there been similar episodes of pain in the past? Is the pain different than that of a previous condition that has been experienced, or is it similar? 13. Questions about the associated symptoms Is there shortness of breath? Fever or chills? Cough? Nausea or vomiting? Sweating? 14. Questions about risk factors for disease Risk factors for atherosclerotic heart disease (also known as coronary artery disease) Smoking High blood pressure High cholesterol Diabetes Family history 15. Coronary Artery Disease, or CAD: A blockage in the heart blood vessels that reduces blood flow and oxygen to the heart muscle itself. This can cause pain known as angina. It's a symptom of heart disease but typically does not cause permanent damage to the heart. It is, though, a sign that you are a candidate for a heart attack at some point in the future. The chest pain may spread to your arm, shoulder, jaw, or back. It may feel like a pressure or squeezing sensation. 16. Risk factors for pulmonary embolus (blood clot to the lung) Prolonged inactivity such as bed rest, long car or airplane trips Recent surgery Fractures Birth control pill use (particularly if the patient smokes cigarettes) Cancer 17. Pulmonary embolism: When a blood clot travels through the bloodstream and lodges in the lungs, this can cause acute pleuritis, trouble breathing, and a rapid heartbeat. It may also cause fever and shock. Pulmonary embolism is more likely following deep vein thrombosis or after being immobile for several days following surgery or as a complication of cancer. 18. Risk factors for aortic dissection High blood pressure Marfan syndrome Ehlers-Danlos syndrome Polycystic kidney disease Cocaine use Pregnancy 19. Coronary artery dissection: A variety of factors can cause this rare but deadly condition, which results when a tear develops in the coronary artery. It may cause a sudden severe pain with a tearing or ripping sensation that goes up into the neck, back, or abdomen. 20. Physical examination helps refine the differential diagnosis. While chest pain may be the initial complaint, often the whole body needs to be examined. Example components of the physical exam may include: 21. Vital signs Blood pressure (BP), pulse rate (PR), respiratory rate (RR), temperature, and Oxygen saturation (O2 sat) which measures the amount of oxygen being carried by red blood cells in the bloodstream. 22. Head and neck Looking for neck vein distension or bulging Listening over the carotid arteries for bruits (abnormal sounds) or murmurs that begin in the heart and radiate to the neck 23. Chest wall Palpate for rib or muscle tenderness Look for rashes including the rash of shingles (zoster) 24. Causes of Chest pain due to neurologic disorders: The following medical conditions are some of the possible causes of Chest pain due to neurologic disorders. There are likely to be other possible causes. Intercostals nerve trauma Herpes zoster neuritis Dorsal root trauma Radiculitis 25. Musculoskeletal chest wall pain ( due to trauma, overuse, or costochondritis): Often suggested by history Pain typically persistent (typically days or longer), worsened with passive and active motion Diffuse or focal tenderness 26. Fibromyalgia: Nearly constant pain, affecting multiple areas of the body as well as the chest Typically, fatigue and poor sleep Multiple trigger points Herpes zoster infection: Sharp, band-like pain in the midthorax unilaterally 27. Lungs Listen for abnormal lung sounds like crackle or wheeze or decreased air entry with inspiration Listen for rubs (a friction sound made by two rough surfaces rubbing against each other) that may be heard in pleurisy 28. Pleuritis: Also known as pleurisy, this condition is an inflammation or irritation of the lining of the lungs and chest. You likely feel a sharp pain when you breathe, cough, or sneeze. The most common causes of pleuritic chest pain are bacterial or viral infections, pulmonary embolism, and pneumothorax. Other less common causes include rheumatoid arthritis, lupus, and cancer. 29. Pneumonia or lung abscess: These lung infections can cause pleuritic and other types of chest pain, such as a deep chest ache. Pneumonia often comes on suddenly, causing fever, chills, cough, and pus coughed up from the respiratory tract. 30. Pneumothorax: Often caused by an injury to the chest, pneumothorax occurs when a part of the lung collapses, releasing air into the chest cavity. This can also cause pain that gets worse when you breathe as well as other symptoms, such as low blood pressure. 31. Pulmonary hypertension: With chest pain resembling that of angina, this abnormally high blood pressure in the lung arteries makes the right side of the heart work too hard. Asthma: Causing shortness of breath, wheezing, coughing, and sometimes chest pain, asthma is an inflammatory disorder of the airways. 32. Heart Listen for abnormal heart sounds, murmurs or rubs (which may be heard with inflammation of the heart lining, called pericarditis) Listen for muffled or indistinct heart tones that can be associated with excess fluid in the pericardium, the sac that surrounds the heart 33. Myocardial infarction (heart attack): This reduction in blood flow through heart blood vessels causes the death of heart muscle cells. Though similar to angina chest pain, a heart attack is usually a more severe, crushing pain usually in the center or left side of the chest and is not relieved by rest. Sweating, nausea, shortness of breath, or severe weakness may accompany the pain. 34. Myocarditis: In addition to chest pain, this heart muscle inflammation may cause fever, fatigue, fast heart beat, and trouble breathing. Although no blockage exists, myocarditis symptoms can resemble those of a heart attack. Pericarditis: This is an inflammation or infection of the sac around the heart. It can cause pain similar to that caused by angina. However, it often causes a sharp, steady pain along the upper neck and shoulder muscle. Sometimes it gets worse when you breathe, swallow food, or lie on your back. 35. Hypertrophic cardiomyopathy: This genetic disease causes the heart muscle to grow abnormally thick. Sometimes this leads to problems with blood flow out of the heart. Chest pain and shortness of breath often occur with exercise. Over time, heart failure may occur when the heart muscle becomes very thickened. This makes the heart work harder to pump blood. Along with chest pain, this type of cardiomyopathy may cause dizziness, lightheadedness, fainting, and other symptoms. 36. ?Mitral valve prolapse: Mitral valve prolapse is a condition in which a valve in the heart fails to close properly. A variety of symptoms have been associated with mitral valve prolapse, including chest pain, palpitations, and dizziness, although it can also have no symptoms, especially if the prolapse is mild. 37. Abdomen Palpate for tenderness or masses Listen for bruits over the aorta 38. Gastrointestinal Gastroesophageal reflux disease (GERD): Also known as acid reflux, GERD occurs when stomach contents move back into the throat. This may cause a sour taste in the mouth and a burning sensation in the chest or throat, known as heartburn. Factors that may trigger acid reflux include obesity, smoking, pregnancy, and spicy or fatty foods. Heart pain and heartburn from acid reflux feel similar partly because the heart and esophagus are located close to each other and share a nerve network. 39. Esophageal contraction disorders: Uncoordinated muscle contractions (spasms) and high-pressure contractions (nutcracker esophagus) are problems in the esophagus that can cause chest pain. Esophageal hypersensitivity: This occurs when the esophagus becomes very painful at the smallest change in pressure or exposure to acid. The cause of this sensitivity is unknown. 40. Esophageal rupture or perforation: A sudden, severe chest pain following vomiting or a procedure involving the esophagus may be the sign of a rupture in the esophagus. Peptic ulcers: A vague recurring discomfort may be the result of these painful sores in the lining of the stomach or first part of the small intestine. More common in people who smoke, drink a lot of alcohol, or take pain-killers such as aspirin or NSAIDs, the pain often gets better when you eat or take antacids. 41. Hiatal hernia: This common problem occurs when the top of the stomach pushes into the lower chest after eating. This often causes reflux symptoms, including heartburn or chest pain. The pain tends to get worse when you lie down. Pancreatitis: You may have pancreatitis if you have pain in the lower chest that is often worse when you lie flat and better when you lean forward. 42. Gallbladder problems: After eating a fatty meal, do you have a sensation of fullness or pain in your right lower chest area or the right upper side of your abdomen? If so, your chest pain may due to a gallbladder problem. 43. Extremities Feel for pulses 44. Rib: Pain from a rib fracture may worsen with deep breathing or coughing. It is often confined to one area and may feel sore when you press on it. The area where the ribs join the breastbone may also become inflamed. Muscle strain: Even really hard coughing can injure or inflame the muscles and tendons between the ribs and cause chest pain. The pain tends to persist and it worsens with activity. Shingles: Caused by the varicella zoster virus, shingles may prompt a sharp, band-like pain before a telltale rash appears several days later.