DIFFERENTIAL DIAGNOSIS

1
DIFFERENTIAL DIAGNOSIS EVALUATION OF CHEST PAIN

• Arnold E. Cuenca
• MS-III
• Western University of Health Sciences
• College of Osteopathic Medicine of the Pacific

2
CHEST PAIN MAP
Herpes Zoster
Drug Abuse
anxiety
Viral
Pneumothorax
Psych
constrictive
CHEST PAIN
Musculoskeletal
Pleuritic
Pericarditis
Visceral
Cardiac tamponade
CAD
Aortic Dissection
PE
GERD
MI
Ischemia
3
PLEURITIC CHEST PAIN

• Pneumothorax
• History/Symptoms
• Acute onset of dyspnea, spontaneous
• History of smoking
• History of underlying disease (COPD)
• Physical Exam
• Young
• Increased resonance to percussion
• Decreased fremitus
• tachypnea
• Diagnostic Evaluation
• CXR tracheal deviation to contralateral side

4
PLEURITIC CHEST PAIN

• Pericarditis
• History/Symptoms
• Improves with sitting forward
• Radiates to shoulder/trapezius
• Simultaneous fever and pain 1-2 weeks after viral
  illness (Cocksackie A and B, EBV, etc.)
• History of TB
• Physical Exam
• Pericardial rub at LLSB
• Pulsus Paradoxicus (tamponade)
• Kussmauls sign (constrictive pericarditis)
• Diagnostic Evaluation
• EKG
• diffuse ST elevation with associated PR
  depression
• echocardiogram/CT/MRI
• pericardial effusion and cardiac tamponade

5
PLEURITIC CHEST PAIN

• Pulmonary Embolism
• History/Symptoms
• Dyspnea
• Hemoptysis
• History of Trauma
• History of Hypercoagulability (Protein C, Protein
  S defic.)
• stasis
• Physical Examination
• Tachypnea
• Tachycardia
• Signs of Right heart strain
• Loud P2
• S3 increased with inspiration
• Right ventricular heave

6
PLEURITIC CHEST PAIN

• Pulmonary Embolism (continued)
• Diagnostic Evaluation
• EKG S1Q3T3 pattern, tachycardia
• ABG hypoxia, hypocarbia, respiratory alkalosis
• CXR
• Atelectasis
• Westermark sign
• Hamptons Hump
• Pleural effusion
• V/Q scan best initial test if CXR is clear
• Doppler U/S detect proximal DVT
• Pulmonary angiogram (gold standard)

7
VISCERAL CHEST PAIN

• GERD
• History/Symptoms
• Related to food
• Worse when in supine position
• Physical Examination
• May be normal
• Diagnostic Evaluation
• Trial of antacid, H2 blockers, PPi
• Bernstein Test
• Acid instillation into esophagus producing pain

8
VISCERAL CHEST PAIN

• Aortic Dissection
• History/Symptoms
• Abrupt, tearing pain to back
• History of Connective Tissue D/O (e.g. Marfans
  syndrome)
• Physical Examination
• Unequal BP in both arms
• Blowing diastolic murmur
• Aortic regurgitation as a result of aortic valve
  root involvement
• Diagnostic Evaluation
• CXR widened mediastinum
• Transesophageal echocardiogram/Aortogram

9
VISCERAL CHEST PAIN Coronary Artery Disease

• CAD Risk Factors
• Hyperlipidemia
• Hypercholesterolemia
• Hypertension
• Diabetes Mellitus
• Family History of CAD
• Smoking
• male

10
VISCERAL CHEST PAINCoronary Artery Disease

• Ischemia
• History/Symptoms
• Stable angina symptoms exacerbated w/ exertion
  for several minutes relieved w/ rest
• Unstable angina symptoms at rest or significant
  change in existing angina
• Atypical angina isolated symptoms (jaw pain,
  dyspnea) esp. found in pt.s w/ underlying
  disease (e.g. DM)
• Radiation to jaw, shoulder, back, ulnar aspect of
  arm

11
VISCERAL CHEST PAIN Coronary Artery Disease

• Ischemia (continued)
• Physical Exam
• Retina A-V nicking secondary to HTN
• S4
• Arterial bruits
• Decreased/absent peripheral pulses
• xanthomas
• Diagnostic Evaluation
• EKG ST depression
• Exercise stress test
• Normal, persantine, thallium

12
VISCERAL CHEST PAIN Coronary Artery Disease

• Myocardial Infarction
• History/Symptoms
• CAD Risk Factors
• Diaphoresis, dyspnea, radiation to jaw,
  shoulders, back, arm, feeling of impending doom
• Physical Exam
• May be normal
• S4, pulmonary edema, hypotension, mitral
  regurgitation murmur
• Diagnostic Evaluation
• EKG ST elevation (Tombstone pattern)
• CK-MB
• Increase 3 hours after initial onset
• Peaks at 12-24 hours