DDX 1 - Week 7

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DDX 1 - Week 7
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Chest Pain

• Cardiac
• Diffuse
• Substernal or precordial
• Radiating to medial arm or to jaw
• Often exertion related
• 10-30 min. usually

• Non-Cardiac
• Brief-Continuous
• Localized
• Radiation uncommon unless along rib (dermatome)
• Reproducible if neuromusculoskeletal
• Organ referral not reproducible

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Non-Cardiac Chest Pain

• Muscular
• Strain
• Contract/Stretch
• Pectorals (major Minor, intercostals, serratus
  anterior
• Trigger Point
• reference zone of pain for individual muscle
• possible pain at end-range stretch

• Skin
• Mondors Syndrome
• thrombosis of superficial vein
• Herpes Zoster (Shingles)
• varicella virus in DRG
• follows dermatome
• vesicles

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Non-Cardiac Chest Pain

• Referred
• Thoracic facet, C-spine OA
• Pleural
• Hx of URI
• local unilateral pain
• chest film recumbent for fluid level
• Esophageal spasm
• mimics angina
• responds to nitro
• GI

• Ribs
• Fracture
• posterolateral most common
• compression pain
• need oblique x-rays
• Tietzes Syndrome
• unilateral pain
• costochondral junction of upper rib
• Slipped rib, Rib subluxation

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Angina

• Stable
• Exertion related
• Usually lt10 min..
• Rest nitro help
• ST depression on EKG
• Negative enzymes
• Due to athero

• Unstable Prinzmetal
• Occurs at rest
• gt10 min.
• Nitro usually helps
• ST depression or elevation
• Unstable due to complicated athero
• Prinzmetal due to vasospasm

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MI Heart Attack

• Damage releases enzymes including Tropinin and
  CPK in the early phase
• EKG changes include axis deviation away from the
  damaged area, significant Q waves, ST-depression
  or elevation
• Prediction of future events is based on
  combination of lab and EKG

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Manual Therapy for Stable Angina

• Randomized, prospective study
• 275 patients referred for coronary angiography
  were divided into cervicothoracic angina (CTA)
  positive or CTA negative
• 75 of the CTA-positive reported improvement in
  pain and general health whereas 22-25 of the
  CTA-negative group reported improvement
• Whereas pain intensity improved in both groups,
  SF-36 changes were found in the CTA-positive
  group only

Christensen HW, et al. JMPT 200528664-661.
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Palpitations

• Patient may report one of several complaints
• hears heart beat
• feels heart skip a beat
• heart races
• Determine frequency, situational occurrence, and
  use of medications
• Determine whether tachycardia is abrupt in onset

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Tachycardia

• Atrial source may respond to a vagal stimulation
• Evaluate patient for associated murmurs
• Resting and stress ECGs
• Echocardiogram for suspected MVP

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Main Mechanisms and Typical Electrocardiographic
Recordings of Supraventricular Tachycardia
Delacretaz E. N Engl J Med 20063541039-1051
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Clinical Clues to the Differential Diagnosis of
Supraventricular Tachycardia (SVT)
Delacretaz E. N Engl J Med 20063541039-1051
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Difficulty Breathing (Dyspnea)

• Difficulty due to pain on full inspiration?
• direct trauma
• muscle strain
• More of a sense of tightness or pressure?
• radiation into arm or jaw? (cardiac)
• associated complaints of headache, dizziness,
  multiple joint pains, etc? (depression)
• With exertion? (determine the degree)
• Position related?

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Respiratory Signs Symptoms

• Cough common with many resp. disorders
• Chronic non-productive cough cause is one of the
  following in 75 of cases
• post-nasal drip
• Chronic bronchitis (smoker)
• Hyperactive airway disease (cough-variant asthma)
• GI reflux
• Sputum is a non-specific indicator
• Wheezes indicate obstruction (mucus or narrowed
  airway)

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Respiratory Disorders

• Obstructive
• Exhalation most effected
• Obstruction due to mucus or bronchial
  constriction
• Decrease in FEV1
• Increased residual volume
• Wheezes rhonchi
• Asthma, chronic bronchitis, emphysema, and
  bronchiectasis

• Restrictive
• Effects all aspects or respiration
• Sources are pulmonary extra including
• neuromuscular
• skeletal deformity
• pleural
• Rales are more prevalent

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Clinical Appearance of COPD

• Blue Bloater
• Centrilobular
• Blockage of distal bronchioles
• Decreased CNS sensitivity to CO2 leads to
  cyanosis
• Not in apparent distress
• Chronic cough smoker

• Pink Puffer
• Panacinar
• Destruction of distal alveoli
• 25 of body energy to breath
• Thin, frail, flushed
• Breaths through pursed lips
• Barrel-chest appearance

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Asthma

• Instrinsic
• Usually adult gt 40
• Causes include prolonged URI, smoking,
  occupational exposure to toxins
• No allergy relationship

• Extrinsic
• Onset in childhood
• Family Hx of allergy
• Testing with
• spirometry
• with challenge
• allergy testing
• Monitor with peak flow meter
• Distinguish from hyperactive airway

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New Theories

• Favoring of Th1 helper cell response which is
  non-inflammatory includes
• Presence of younger siblings
• Exposure to daycare
• Exposure to animals in first 6 months
• Exposure to TB, measles, hepatitis A infection
• Exposure to rural environment

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New Theories

• Favoring the inflamattory Th2 helper cell
  response includes
• Urban environment
• Antibiotic use
• Western lifestyle including diet
• Sensitization to dust mites and cockroaches

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Asthma References

• Mackay IR, Rosen FS. Asthma. N Engl J Med
  2003344350-362.
• Ball TM, Castro-Rodriguez JA, Griffith KA, et al.
  Siblings, day-care attendance, and the risk of
  asthma and wheezing during childhood. N Engl J
  Med 2000343538-543.
• Celdon JC,Wright RJ, Litonjua AA, et al. Day care
  attendance in early life, maternal history of
  asthma, and asthma at the age of 6 years. Am J
  Critical Care Med 20031671239-1243.
• Sears MR, Greene JM, Willan AR, et al. Long-term
  relation between breastfeeding and development of
  atopy and asthma in children and young adults a
  longitudinal study. Lancet 2002360901-907.
• Siltanen M, Kajosaari M, Poussa T, et al. A dual
  long-term effect of breastfeeding on atopy in
  relation to heredity in children at 4 years of
  age. Allergy 200358524-530.
• Ownby DR. Cole Johnson C, Peterson EL. Exposure
  to dogs and cats in the first year of life and
  risk of allergic sensitization at 6 to 7 years of
  age. JAMA 2002288963-972.
• Eysink PE, Bindels PJ, Stapel SO, et al. Do
  levels of immunoglobulin G antibodies to foods
  predict the development of immunoglobulin E
  antibodies to cat, dog and/or mite? Clin Exp
  Allergy 200232556-562.

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Asthma Medications

• Acute Phase Medications
• Epinephrine
• Beta-Agonists (ventolin)
• Methyl-Xanthines (theophyline)

• Prophylactic Medications
• Cromolyn sodium (Intal)
• Leukotrine receptor antagonists (eg. Zafirlukast)
• Beta 2 agonists (eg. Salmeterol)
• Oral and aerosol corticosteroids

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Guidelines for Exercise Induced Bronchospasm (EIB)

• Perform warm-up 45-60 min. before event or
  workout
• Exercise in warm, humid air
• Avoid intense exercise or keep workout short
• Try sports which involve short bursts of activity
• Breathe through nose as much as possible
• Control breathing to prevent hyperventilation