Differential Dx Chest Pain


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Complete and detailed diagnosis of chest pain

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  • More so than perhaps any other clinical problem the chest pain differential diagnosis is encyclopedic in complexity and scope. \n
  • This talk will focus on developing in a short period of time the most detailed differential diagnosis for chest pain possible. \n
  • The problems inherent in chest pain can not be overstated or underestimated. \n\nChest pain represents a problem in which encompassed in its bewildering breadth of conditions manifesting with chest pain lies the leading cause of death in the developed world, the leading cause of successful malpractice claims (20% of all dollars paid out in malpractice actions relate to missed myocardial infarction), and for the justifiable fear of missing a life threatening cause of chest pain lies the source of many unnecessary hospitalizations in our society. \n
  • Chest pain syndromes encompass the entire pantheon of internal medicine diseases and pathophysiological processes. \n
  • The problem of chest pain is related principally to the fact that the majority of causes of chest pain are related to pain in an organ rather than pain in a cutaneous or musculoskeletal structure and therefore the diagnostician must confront the dual problems of poor spatial mapping of the pain’s origin as well as the confusion attendant to the phenomena of pain radiation. \n\nSomatic pain reflects pain as perceived by the neo-cortex, while visceral pain reflects pain as perceived by the more primitive and less accurately mapped reptilian nervous system. \n
  • This table illustrates the fundamental clinical differences in somatic vs visceral pain syndromes. \n
  • While at the head of the list, and of undoubtable importance (4 Jumbo Jets worth of patient’s die of AMI every day in the USA), yet the minority of the patient’s presenting to an USA Emergency Room with chest pain turn out to be suffering from acute myocardial infarction or unstable coronary artery disease. \n\nThe commonality for all the chest pain etiologies listed on this slide is their precise relationship to diseases of the heart. \n\nNote that IHSS (idiopathic hypertrophic subaortic stenosis) represents the older and less favored way to describe the dynamic subaortic outflow tract obstruction characteristic of asymmetrical LV hypertrophy. \n
  • While in the USAF I had the opportunity to review in detail the lethal missed diagnosis of pneumomediastinum occurring in a National Guard pilot who was ferrying a F-100 from Arizona to Florida where it was to be used as a target drone. \n\nHe developed severe chest pain enroute, declared an in-flight emergency and was evaluated at Charity Hospital in New Orleans. He died due to failure to consider the diagnosis. The great tragedy of the case related to the high likelihood of survival attendant to prompt treatment with hyperbaric/dive chamber therapy. \n
  • The next series of slides are related to a more exhaustively detailed exploration of the potential causes for development of a spontaneous pneumothorax. \n
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  • In this group, the most interesting and most important diagnostic entity is pulmonary embolism. While much less frequently seen than myocardial infarction, it remains a highly lethal condition with reported rates of one hour mortality as high as 60% in some historical clinical series. It rightfully is more feared than coronary occlusive disease. \n
  • In these GI causes of potentially threatening chest pain, the most feared entity is Boerhauve’s Syndrome as GI tract soiling of the mediastinum is of greater technical complexity in its management than the more common GI tract soiling of the peritoneal cavity. \n\nOne of the most interesting cases of chest pain that I am personally aware of was the case of gut ischemia which was developed by one of our staff GYN physicians in Eagle Pass Texas. I was consulted for what was felt to be an inferior wall myocardial infarction. The physician was in intense vagal pain, diaphoretic, shocky but with a normal EKG, emergency cardiac ultrasound confirmed completely normal LV segmental wall motion. Emergency Contrast CT of the chest and abdomen showed total occlusion of the origin of the superior mesenteric artery due to a mid-gut volvulus. \n
  • Syndrome X, the object of intense research interest in cardiology for over 40 years represents the clinical perplexity of normal coronary arteries combined with the presence of predictable exertional angina, reproducible and repetitively abnormal non-nuclear and nuclear stress tests. This syndrome is also characterized by some authorities by the presence of increased levels of coronary sinus lactic acid during RV pacing. \n\nClosely related to Syndrome X due to its pathophysiology being related to micro-circulatory dysfunction is Takotsubo Cardiomyopathy or broken heart syndrome. While originally \n
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  • Da Costa Syndrome (old soldier’s heart) was orginally described during the Civil War \n\nPsychological chest pain syndromes are among the most common if not the most common underlying cause for chest pain ED visits. \n
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  • Differential Dx Chest Pain

    1. 1. Chest PainDifferential Dx & Clinical Pearls Frank W Meissner, MD, RDMS, RDCS FACP, FACC, FCCP, FASNC, CPHIMS, CCDS 1
    2. 2. Peril’s & Pearls - Chest Pain Dx In the absence of CAD, the most important “LAB” test in the patient with chest pain is the AP chest X-RAY, it provides valuable visual clues to many life-threatening causes of non-cardiac chest pain While not a highly sensitive test, there are highly specific findings often present suggesting relevant Dx The most important procedure in the evaluation of the stable patient with chest pain and a normal EKG is a METICULOUS, PRECISE, EXACTING (TIME- CONSUMING) HISTORY. 2
    3. 3. “The Time Honored statement is still true today” it takes a professional lifetime for physicians to learn how to take a history. 3
    4. 4. The Problem of Pain is thecompelling 1940 book by C. S. Lewis that provides an intellectual Christianresponse to theeternal question of existential suffering. For patients with a Christianviewpoint on life it is an aid toconfronting and understanding the suffering dimension of illness. 4
    5. 5. The singlemost important book to read about chest painsyndromes. Of value to medical student,house-officer, staff physicians.Highly distilled and relevant clinical wisdom. http://www.amazon.com/Chest-Pain-J-Willis-Hurst/dp/0879934824/ref=sr_1_1? s=books&ie=UTF8&qid=1341675849&sr=1-1&keywords=Chest+Pain 5
    6. 6. The Problem of Chest Pain Somatic(Precisely Vs Mapped) Visceral (Vague/Enteric Pain /Vagal) Pain 6
    7. 7. The Problem of Chest Pain Somatic Visceral Diffuse & poorly localized, felt inLocalization Focused dermatomal distribution, radiates Sharp, Aching, Quality Vague discomfort Burning, StabbingAssociated Motor Motor reflexes + Vagal SymptomsSymptoms Reflexes (faint, nausea, sweats) Tissue Organ Distention/Contraction/ Triggers Injury Ischemia 7
    8. 8. LIFE THREATENINGUnstable Angina - Acute Coronary SyndromeMyocardial InfarctionIV & Non-IV Drug Addiction (esp Cocaine)Cardiac Arrhythmia (esp AFib or PSVT)Critical Aortic Stenosis (common >75%)Critical Mitral Stenosis (rare <10% cases)Asymmetrical LV Hypertrophy (ASH)/IHSSDilated CardiomyopathyMalignant Dz Of The Breast 8
    9. 9. LIFE THREATENINGPericarditis With TamponadeToxicological (Lead Poisoning, CO Poisoning, Cyanide)Aortic DissectionSpontaneous PneumothoraxPneumomediastinum (Diving accident or loss of cabin pressure at altitude)Decompression Sickness (“Chokes”)Air EmbolismLymphomaSuperior Vena Cava Syndrome 9
    10. 10. Spontaneous Pneumothorax (Detailed Diff Dx) Primary (idiopathic) Secondary (Airway Disease) Emphysema Cystic Fibrosis Status Asthmaticus 10
    11. 11. Spontaneous Pneumothorax (Detailed Diff Dx) Secondary (Infectious Disease) AIDS with Pneumocystis carinii Non AIDS related Pneumocystis carinii PNA TB Necrotizing PNA 11
    12. 12. Spontaneous Pneumothorax (Detailed Diff Dx) Secondary (Interstitial Disease) Sarcoidosis Idiopathic pulmonary fibrosis Pulmonary histiocytosis X Lymphangioleimyomatosis Tuberous sclerosis 12
    13. 13. Spontaneous Pneumothorax (Detailed Diff Dx) Secondary (Connective Tissue Dz) RA Ankylosing Spondylitis Polymyositis & dermatomyositis Scleroderma Marfan’s Syndrome Ehler’s-Danlos Syndrome 13
    14. 14. Spontaneous Pneumothorax (Detailed Diff Dx) Secondary (Cancer) Sarcoma Primary Lung Metastatic cancer Non-pulmonary/non-interstitial cancers Lymphoma Hodgkin’s Disease 14
    15. 15. Spontaneous Pneumothorax (Detailed Diff Dx) Miscellaneous Infarction Chemical/Radiation pneumonitis Drug Toxicity (O2, pentamidine) Drug Abuse (Cocaine, Heroin, MJ) Pneumoperitoneum (via diaphragm defects) 15 12
    16. 16. LIFE THREATENING Pulmonary Artery Hypertension Pneumonia Pulmonary Embolism/Infarction Oncological disease of bone (i.e., multiple myelomaor bone met to T-spine/sternum/ribs) 16
    17. 17. LIFE THREATENINGEsophageal Rupture (Boerhauve’s Syndrome)Acute CholecystitisAcute PancreatitisPerforated Gastric/Duodenal UlcerRuptured ViscusBowel Infarction 17
    18. 18. NON LIFE THREATENINGSyndrome X (Angina + ST depression on Stress EKG + Nml CA’s)Takotsubo Cardiomyopathy (Transient Apical Ballooning) (Broken Heart Syndrome)Barlow’s Syndrome (Click-murmur or Mitral Valve Prolapse Syndrome)Mondor’s Syndrome (Superficial Thrombophlebitis of Chest Wall)Nonmalignant Dz’s Of The BreastPericarditis Without TamponadeDressler’s Syndrome (Postmyocardial Infarction Syndrome) 18
    19. 19. NON LIFE THREATENINGViral or Non-viral (Rheumatological) PleurisyFamilial Mediterranean FeverTietze’s Syndrome (Chostochondritis)Cyriax’s (Slipping Rib) SyndromePrecordial “Catch” Syndrome (Texidor’s Twinge) Herpes Zoster 19
    20. 20. NON LIFE THREATENING Cervical/thoracic disk or joint disease (e.g., T-spinecompression fractures in the elderly)Thoracic outlet syndromesRib fractureShoulder Pain/InjuryShoulder-Hand Syndrome (Cardiac Causalgia - RSD)Peptic Dz (Esophagitis (GERD) vs Ulcer Dz)Pill-induced Esophagitis - HIV Assoc Esophageal Dz“Nutcracker” esophagitis or esophageal spasm 20
    21. 21. Detailed Diff DxThoracic Outlet SyndromesCervical Spine Cervical Strain Herniated Cervical Intervertebral Disk Cervical Spondylosis Degenerative Disease Osteoarthritis Spinal Cord Tumors 21
    22. 22. Detailed Diff DxThoracic Outlet SyndromesBrachial Plexopathy Superior Pulmonary Sulcus Tumor Pancoast’s Tumor Trauma/Inflammation Spinal Cord Tumors 22
    23. 23. Detailed Diff Dx Thoracic Outlet SyndromesPeripheral Neuropathy (Medical) Entrapment neuropathies Scalenus Anticus Syndrome Cervical Rib Syndrome Costoclavicular Syndrome Carpal-Tunnel Syndrome (median nerve) Ulnar Nerve (elbow entrapment)Tumor or Trauma Radial Nerve Suprascapular Nerve
    24. 24. Detailed Diff Dx Thoracic Outlet SyndromesArterial Abnormalities Arteriosclerosis-aneurysm (occlusive) Thromboangiitis obliterans Arterial Embolism Functional Impairment (Raynaud’s Disease) Reflex (Vasomotor Dystrophy) CausalgiaVasculitis - Collagen Vascular Dz 24
    25. 25. Detailed Diff Dx Thoracic Outlet Syndromes Congenital Vascular Abnormalities Non-exertional Upper Ext Venous Thrombophlebitis or Thrombosis Paget-Schroetter Dx or Paget-von Schrotter Dz (effort-induced UE venous thrombosis) Mediastinal Venous Obstruction 25
    26. 26. Detailed Diff Dx Thoracic Outlet Syndromes Inflammatory Shoulder Disorders Bursitis Fibrositis Myositis Tendinitis Video Terminal Display Syndrome Multiple Sclerosis 26
    27. 27. Non Life ThreateningHyperventilation SyndromePanic Attack/Panic DisorderDa Costa Syndrome (Old Soldier’s Heart) (neurocirculatory asthenia)(Cardiac Neurosis)Undifferentiated Anxiety D/ODepressionConversion D/OFactious Illness Munchausen Syndrome Malingering 27
    28. 28. The Take HomeChest Pain Evaluation is much morecomplicated than simply R/O MIThe Job Is NOT done until you have adefined and defensible explanation for theepisode or episodes of chest painDx is most dependent on a careful, detailed,and meticulous history combined with afocused physical examination NOT bydeploying exhaustive and expensive testing 28