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Mrs A is a 78-year-old female who presents with crushing central chest…
Mrs A is a 78-year-old female who presents with crushing central chest pain for 20 minutes.
Cardiac
Ischemic*
Angina
known history of coronary artery disease; chest discomfort on exertion; no change in intensity, frequency, or duration; associated diaphoresis, nausea/vomiting, or shortness of breath
Unstable angina (Acute coronary syndrome)*
•Crushing central chest pain
•Radiates to neck/left arm
•Associated
nausea/SOB/sweatiness
•Cardiovascular risk factors
•May be normal
•General: sweaty, SOB, in pain
•CVS: S4 gallop, JVP distension,
signs of heart failure,
brady/tachycardic
Myocardial infarction
Chest pain radiates to both arms
Hypotension
S3 gallop
Diaphoresis
Pleuritic chest pain
Palpation of tender area reproduces chest pain
Non-ischemic
Aortic dissection*
•Tearing chest pain of very sudden
onset
•Radiates to back
•Pain in other sites e.g. arms, legs,
neck, head
•Unequal arm pulses or BPs
•May be acute aortic regurgitation
•May be new neurological
symptoms due to involvement of
carotid/vertebral arteries
Pericarditis
•Retrosternal/precordial pleuritic
chest pain
•Relieved by sitting forward
•May radiate to trapezius
ridge/neck/shoulder
•Viral prodrome common
•Pericardial rub (stepping in snow)
•Tachycardia
•JVP distension and pulsus
paradoxus may indicate tamponade
Myocarditis
•Chest pain
•Palpitations
•Fever
•Fatigue
•Dyspnoea
•Signs of congestive cardiac failure
•Soft S1, S4 gallop
•Fever
•Tachypnoea
Respiratory
Pulmonary embolism*
•Pleuritic chest pain
•Dyspnoea
•Haemoptysis
•Risk factors (long haul flight,
recent surgery, immobility)
•CVS: tachycardia, JVP distension,
RV heave, loud P2, right S4
•RS: tachypnoea, clear chest
•CALVES: look for DVT
•SBP<90/pulselessness/persistent
bradycardia = “massive PE”
Pneumothorax
•Sudden onset pleuritic chest pain
•May be SOB if large
•Risk factors e.g. Marfan’s
appearance, COPD/asthma
Ipsilateral
•Reduced chest expansion
•Absent breath sounds
•Hyperresonance
Tension pneumothorax
•JVP distension, hypotension
•Tracheal deviation (away from
affected side)
Pneumonia with pleurisy*
Pneumonia
•Fever
•Shortness of breath
•Productive cough
•Pleuritic chest pain
•Confusion
Pleurisy
•Pleuritic chest pain
•May be: dry cough, fever,
dyspnoea
Pneumonia
•Tachypnoea, cyanosis
•Coarse crepitations and bronchial
breathing
•Dullness to percussion
•Increased vocal resonance/tactile
vocal fremitus
Pleurisy
•Pleural rub
Trauma
Atypical
Asthma & COPD
Malignancy
Gastrointestinal
Esophageal rupture*
rare but life threatening.
Consider if chest pain follows violent vomiting, or
if there is hx of esophageal instrumentation. There
may be subcutaneous emphysema.
Gastroesophageal reflux disease
•Retrosternal burning chest pain
•Related to meals, lying, straining
•Water brash
•Usually normal
•May be epigastric tenderness if
associated gastritis
Esophageal spasm
•Intermittent crushing sub-sternal
pain
•Relieved by GTN
•Associated dysphagia
Referred pain from subdiaphragmatic etiology
rare but life threatening.
Consider if chest pain follows violent vomiting, or
if there is hx of esophageal instrumentation. There
may be subcutaneous emphysema.
Others
Musculoskeletal
Costochondritis*
•Costosternal joint pain
•Worse with coughing, twisting
and physical activity
•Tenderness at sternal edges
Herpes zoster
Pain may precede the dermatomal
vesciular eruption. Patients are often worked up
extensively for cardiac disease, until the diagnosis is
revealed days later when vesicles appear.
Cervical spine disorders
unilateral, burning pain in typical dermatome distribution that may occur before appearance of rash and may persist for >1 month
vesicular rash on erythematous base, in unilateral distribution of a dermatome
Psychogenic
Panic disorder/anxiety state