Approach to Chest Pain Differential diagnosis of chest pain

Chest pain or chest discomfort 

may occur due to some minor illness or may be due to some serous illness, or may be an emergency condition.

 

chest pain

 

Causes of serious chest pain –

  • Acute ischemic heart disease, or aortic coronary syndrome,
  • Aortic dissection,
  • Tension pneumotherix,
  • Pulmonary pneumothorex,
  • Pulmonary embolism.

The different condition which may cause  chest pain—

Differential diagnosis of chest pain–

Angina—€

  • angina pain may last from 2- 10 minutes, the character of pain is heaviness, or tightness, sensation around the chest, it is located in the centre of chest. It may be located in the centre of chest and radiate to the left side of chest, left hand, or both arms, neck ,jaw, shoulder, and back. It is precipitated by exertion, exposure to cold or stress.

On examination S4 or MR [ mitral regurgitation ]may be found positive.

Unstable angina—

  • the pain lasts for 10- 20 minutes, and it may be more serious some time life threatening, may be more serious and precipitated by minimum exertion, or may be at rest, not relived by rest and nitro-glycerine.

Acute myocardial infarction 

  • —the pain is similar to angina pain, but last for 30 minute and more, and not relived by nitro-glycerine or rest. The more serious complications are like heart failure and erythematic.

Aortic stenosis 

  • there is characteristic angina pain with ejection systolic systolic murmur radiating to carotids.

Pericarditis 

  • —there is retrosternal pain which may be relived by sitting up and leaning forward, a pericardial friction rub heard on auscultation of pericardium.

Aortic dissection

  • —there is acute sevear pain which is sharp and stabbed knife like felt in the front of chest and radiate to the back. There is the history of chronic hypertension, AR, pericardial rub, cardiac temponad, absent peripheral pulses.

Pulmonary hypertension

  •  —there is pressure pain with dyspnoea, cough, oedema and raised JVP.

Pneumonia or pleuritis

  • there is pleuritic pain increasing on deep inspiration, may be unilateral, or with dyspnoea, cough, fever, and plural rub.

Pulmonary embolism

 

  • —there is acute sevear chest pain, lasting for few minutes to hours with dyspnoea, tachycardia, and hypotension.

Spontaneous pneumothorex

 

  • —there is sudden onset of sevear chest pain with pleuritic quality, unilateral with syspnea and decreased breath sound on the same side.

Esophageal reflux

 

  • —there is burning substernal or epigestric pain lasting for more then an hour and increase on lying down.

Esophageal spasm

 

  • —resembles angina pain but last for upto 30 minuts with history of hyper acidity.

Peptic ulcers

 

  • —there is prolong burning epigestric pain, relived with food intake, or antacid.

Gall bladder disease

 

  • —there is burning pain in epigestrium or right hypo chondrium following a meal.

Musculoskeletal disease

 

  • —there is aching pain, fatigue, aggravated by movement often with tenderness.

Herpese joster

  • —there is sharp or burning pain in dermatome distribution with v esicular rashes.

Assessment of chest pain

  • ECG changes are useful to rule out the ischemic changes of heart disease.
  • History of hyper acidity and peptic ulcer suggest acid peptic disease.
  • Valvuler heart disease often give rise to pulmonary hypertension and chest pain.
  • Causes of pericarditis if present, will be evident.
  • Rashes of herpes zpster are clearly seen.
  • Cervical spondilitis, arthritis, costo chondritis, and other musculoskeletal disorder give rise to chest pain, and stiffness during movement.
  • X-rar, ECG, MRI, CT scan, angiography, echocardiography, ultrasound, serum cardiac markers, etc, aid diagnosis.

This is brief introduction about chest pain.

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