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Differential Diagnosis of Chest Pain

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Differential Diagnosis of Chest Pain This presentation is the property of the Milwaukee County EMS Education Center. Any reproduction or use of this presentation without expressed permission is prohibited. Andrew Irzyk 2015 MCEMS Differential Diagnosis of Chest Pain There are literally dozens of illnesses, injuries and conditions that can cause chest pain. Knowing common signs, symptoms and patient presentations can help you differentiate between different kinds of chest pain. Bottom Line: If you are ever not sure what kind of chest pain you are dealing with, treat it as cardiac and call medical control. Differential Diagnosis of Chest Pain Common Causes of Chest Pain Cardiovascular: Respiratory: ischemia (AMI or PE (pulmonary angina) embolism) pericarditis (irritation pneumothorax of pericardium) pneumonia thoracic aortic pleural irritation dissection hyperventilation (anxiety) Differential Diagnosis of Chest Pain Common Causes of Chest Pain Gastrointestinal: Musculoskeletal: cholecystitis (gall chest wall syndrome bladder/gallstones) (inflamed chest wall) pancreatitis costochondritis (inflamed hiatal hernia (part of stomach pushes through rib cartilage) diaphragm) herpes zoster (shingles) esophageal disease/GERD chest wall trauma peptic ulcers chest wall tumors dyspepsia (indigestion) Non Cardiac Chest Pain Pulmonary Musculoskeletal Pneumonia Costochondritis Pleuritis Cervical Disk Disease Pneumothorax Rib Fracture Pulmonary Embolism Intercostal Muscle Cramp Tumor Other Gastrointestinal Herpes Zoster GERD Disorders of the Breast Esophageal spasm Splenic Infarct Mallory-Weiss Tear Panic Attacks/Anxiety Peptic Ulcer disease Disorder Biliary/Gallbladder Fibromyalgia Disease DKA Pancreatitis CHEST PAIN QUESTIONS TO HELP DIFFERENTIATE CHEST PAIN •CAUSE •ONSET OF PAIN •CHARACTERISTIC OF PAIN •LOCATION OF PAIN •HISTORY •ASSOCIATED SX/SX •AGGRAVATING FACTORS •RELIEVING FACTORS DETERMINE ONSET/DURATION OF PAIN Was it… Sudden? Gradual? Lasts Minutes? Lasts Hours? Varies? Assessment “QUALITY” OF PAIN LOCATION PLEURITIC (sharp pain with inhalation) SITUATIONAL / ANXIETY SPASMODIC (like a spasm) SUBSTERNAL TIGHTNESS OR HEAVINESS CENTER OR ACROSS CHEST LATERAL CHEST PRESSURE LOCALIZED OVER INVOLVED SHARP/LOCALIZED (easy to pinpoint) AREA VISCERAL (hard to pinpoint)/BURNING LOWER CHEST/EPIGASTRIC RADIATES TO JAW, NECK, BACK TEARING / EXCRUCIATING OR ARM VAGUE Visceral Pain Visceral fibers enter the spinal cord at several levels leading to poorly localized, poorly characterized pain. (discomfort, heaviness, dull, aching) Heart, blood vessels, esophagus and visceral pleura are innervated by visceral fibers Because of dorsal fibers can overlap three levels above or below, disease of thoracic origin can produce pain anywhere from the jaw to the epigastrium Parietal Pain Parietal pain, in contrast to visceral pain, is described as sharp and can be localized to the dermatome superficial to the site of the painful stimulus. The dermis and parietal pleura are innervated by parietal fibers. Assessment History Associated Signs/Symptoms AGE DYSPNEA DIAPHORESIS PREVIOUS EPISODES NAUSEA / VOMITING UPPER RESPIRATORY AMS /WEAKNESS /LIGHTHEADEDNESS / INFECTION/FEVER SYNCOPE NEURO CHANGES TRAUMA HYPO OR HYPERTENSION OR UNEQUAL BP STRESS DECREASED OR ABNORNMAL BREATH SOUNDS EMOTIONAL UPSET CYANOSIS HEMOPTYSIS (coughing up blood) CARDIAC DISEASE PULSATING ABD MASS HTN, CAD, ANGINA ABDOMINAL PAIN PHLEBITIS VESICULAR PAIN WITH PALPATION RASH OR LESIONS Assessment AGGRAVATING FACTORS? RELIEVING FACTORS BREATHING REST OR DECREASED MOVEMENT MOVEMENT STRESS POSITION EXERTION SITTING UP OR LEANING AFTER EATING OR ETOH FORWARD LAYING DOWN DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS Now lets match the chest pain diagnosis with the symptoms…. The list items in red italics are the ones that go with the diagnosis…. ANGINA ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies Angina QUALITY LOCATION PLEURITIC SUBSTERNAL SPASMODIC CENTER OR ACROSS CHEST TIGHTNESS OR HEAVINESS LATERAL CHEST PRESSURE- OPPRESSIVE LOCALIZED OVER INVOLVED AREA SHARP/LOCALIZED LOWER CHEST/EPIGASTRIC VISCERAL /BURNING RADIATES TO JAW, TEARING / EXCRUCIATING NECK, BACK OR ARM VAGUE Angina HISTORY ASSOCIATED SX / SX AGE DYSPNEA PREVIOUS EPISODES DIAPHORESIS NAUSEA / VOMITING UPPER RESPIRATORY AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE INFECTION/FEVER NEURO CHANGES TRAUMA HYPO OR HYPERTENSION OR UNEQUAL BP STRESS DECREASED OR ABNORNMAL BREATH SOUNDS EMOTIONAL UPSET CYANOSIS HEMOPTYSIS CARDIAC DISEASE – HTN, CAD, PULSATING ABD MASS ANGINA ABDOMINAL PAIN PHLEBITIS VESICULAR PAIN WITH PALPATION RASH OR LESIONS Angina AGGRAVATING FACTORS RELIEVING FACTORS BREATHING REST OR DECREASED MOVEMENT MOVEMENT POSITION STRESS SITTING UP OR LEANING FORWARD EXERTION DECREASED OR SHALLOW AFTER EATING OR ETOH BREATHING LAYING DOWN DIET SITUATIONAL / ANXIETY MEDICATIONS (nitro) Acute Myocardial Infarction ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies Acute Myocardial Infarction QUALITY LOCATION PLEURITIC SUBSTERNAL SPASMODIC CENTER OR ACROSS CHEST TIGHTNESS OR HEAVINESS LATERAL CHEST PRESSURE- OPPRESSIVE LOCALIZED OVER INVOLVED AREA SHARP/LOCALIZED LOWER CHEST/EPIGASTRIC VISCERAL/BURNING RADIATES TO JAW, TEARING / EXCRUCIATING NECK, BACK OR ARM VAGUE Acute Myocardial Infarction HISTORY ASSOCIATED SX / SX AGE DYSPNEA PREVIOUS EPISODES DIAPHORESIS UPPER RESPIRATORY NAUSEA / VOMITING INFECTION/FEVER AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE TRAUMA NEURO CHANGES STRESS HYPO OR HYPERTENSION OR UNEQUAL BP EMOTIONAL UPSET DECREASED OR ABNORNMAL BREATH SOUNDS CARDIAC DISEASE – HTN, CAD, CYANOSIS ANGINA HEMOPTYSIS PULSATING ABD MASS PHLEBITIS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS Acute Myocardial Infarction AGGRAVATING FACTORS RELIEVING FACTORS BREATHING REST OR DECREASED MOVEMENT MOVEMENT POSITION STRESS SITTING UP OR LEANING FORWARD EXERTION DECREASED OR SHALLOW AFTER EATING OR ETOH BREATHING LAYING DOWN DIET SITUATIONAL / ANXIETY ANTACIDS MEDICATIONS Operational Policy: Transport Destination Operational Policy: Transport Destination Dissecting Aneurysm ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies Dissecting Aneurysm QUALITY LOCATION PLEURITIC SUBSTERNAL SPASMODIC CENTER OR ACROSS CHEST TIGHTNESS OR HEAVINESS LATERAL CHEST PRESSURE- OPPRESSIVE LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC SHARP/ LOCALIZED VISCERAL/BURNING RADIATES TO JAW, NECK, BACK OR ARM TEARING / EXCRUCIATING VAGUE ABDOMEN Aortic dissection Dissecting Aneurysm HISTORY ASSOCIATED SX / SX AGE DYSPNEA DIAPHORESIS PREVIOUS EPISODES NAUSEA / VOMITING UPPER RESPIRATORY AMS /WEAKNESS / LIGHTHEADEDNESS / INFECTION/FEVER SYNCOPE NEURO CHANGES TRAUMA HYPO OR HYPERTENSION OR UNEQUAL BP STRESS DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS EMOTIONAL UPSET HEMOPTYSIS CARDIAC DISEASE – HTN, CAD, PULSATING ABD MASS ANGINA ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION PHLEBITIS RASH OR LESIONS Dissecting Aneurysm AGGRAVATING FACTORS BREATHING MOVEMENT STRESS In other words, it EXERTION hurts badly no AFTER EATING OR matter what. ETOH LAYING DOWN SITUATIONAL / ANXIETY Dissecting Aneurysm RELIEVING FACTORS REST OR DECREASED MOVEMENT POSITION In other words, SITTING UP OR nothing helps it feel LEANING FORWARD better. DECREASED OR SHALLOW BREATHING DIET ANTACIDS MEDICATIONS PERICARDITIS ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies PERICARDITIS QUALITY LOCATION PLEURITIC SUBSTERNAL SPASMODIC CENTER OR ACROSS CHEST/RETROSTERNAL TIGHTNESS OR HEAVINESS LATERAL CHEST PRESSURE- OPPRESSIVE LOCALIZED OVER INVOLVED AREA SHARP/LOCALIZED LOWER CHEST/EPIGASTRIC VISCERAL/BURNING RADIATES TO JAW, TEARING / EXCRUCIATING NECK, BACK OR ARM VAGUE PERICARDITIS HISTORY ASSOCIATED SX / SX AGE DYSPNEA PREVIOUS EPISODES DIAPHORESIS NAUSEA / VOMITING UPPER RESPIRATORY INFECTION/FEVER AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE TRAUMA NEURO CHANGES STRESS HYPO OR HYPERTENSION OR UNEQUAL BP EMOTIONAL UPSET DECREASED OR ABNORNMAL BREATH SOUNDS CYANOSIS CARDIAC DISEASE – HTN, CAD, ANGINA HEMOPTYSIS PHLEBITIS PULSATING ABD MASS ABDOMINAL PAIN VESICULAR PAIN WITH PALPATION RASH OR LESIONS PARADOXICAL PULSE Pericarditis: ECG: PERICARDITIS AGGRAVATING FACTORS RELIEVING FACTORS BREATHING REST OR DECREASED MOVEMENT MOVEMENT POSITION STRESS SITTING UP OR LEANING FORWARD EXERTION DECREASED OR SHALLOW BREATHING AFTER EATING OR ETOH DIET LAYING DOWN ANTACIDS SITUATIONAL / ANXIETY MEDICATIONS PNEUMOTHORAX ONSET/DURATION OF PAIN Sudden Gradual Lasts Minutes Lasts Hours Varies PNEUMOTHORAX QUALITY LOCATION PLEURITIC SUBSTERNAL SPASMODIC CENTER OR ACROSS CHEST TIGHTNESS OR HEAVINESS LATERAL CHEST PRESSURE- OPPRESSIVE LOCALIZED OVER INVOLVED AREA LOWER CHEST/EPIGASTRIC SHARP/LOCALIZED VISCERAL/BURNING RADIATES TO JAW, NECK, BACK OR ARM TEARING / EXCRUCIATING VAGUE Pneumothorax Needle Decompression PNEUMOTHORAX HISTORY ASSOCIATED SX / SX AGE DYSPNEA PREVIOUS EPISODES DIAPHORESIS NAUSEA / VOMITING UPPER RESPIRATORY AMS /WEAKNESS / LIGHTHEADEDNESS / SYNCOPE INFECTION/FEVER NEURO CHANGES TRAUMA HYPO OR HYPERTENSION OR UNEQUAL BP STRESS DECREASED OR ABNORNMAL BREATH SOUNDS EMOTIONAL UPSET CYANOSIS HEMOPTYSIS CARDIAC DISEASE – HTN, CAD, PULSATING ABD MASS ANGINA ABDOMINAL PAIN
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