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.
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 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.
- 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.
- there is characteristic angina pain with ejection systolic systolic murmur radiating to carotids.
- —there is retrosternal pain which may be relived by sitting up and leaning forward, a pericardial friction rub heard on auscultation of pericardium.
- —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.
- —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.
- —there is acute sevear chest pain, lasting for few minutes to hours with dyspnoea, tachycardia, and hypotension.
- —there is sudden onset of sevear chest pain with pleuritic quality, unilateral with syspnea and decreased breath sound on the same side.
- —there is burning substernal or epigestric pain lasting for more then an hour and increase on lying down.
- —resembles angina pain but last for upto 30 minuts with history of hyper acidity.
- —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.
- —there is aching pain, fatigue, aggravated by movement often with tenderness.
- —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.
Fever — Common Causes And Treatment
Clinicians commonly refer to a febrile illness without an initially obvious etiology (sometimes called fever without localizing signs)
- Fever is an elevation in the core body temperature above the individuals normal range that occurs in conjunction with an increase in the hypothalamia temperature set point.
- Fever is defined as a core body temperature of 38Â°C –100.4Â°F.
- Hyperpyrexia, a medical emergency, is defined as a temperature over 41.1Â°C –€€106.0Â°F
- Hyperthermia is an elevated body temperature without a change in the hypothalamus setting.
- Fever is an elevation in the core body temperature above the individuals normal range that occurs in conjunction with an increase in the hypothalami temperature set point.
- Fever is defined as a core body temperature of 38Â°C ==100.4Â°F
- Hyperpyrexia, a medical emergency, is defined as a temperature over 41.1°C (106.0Â°F).
- . Hyperthermia is an elevated body temperature without a change in the hypothalamic setting.
II. Pathophysiology of Fever
- A. Mechanisms of temperature control
- Body temperature is controlled by the hypothalamus, which receives inputs from both the peripheral nerves and from the temperature of the blood supplying the area.
- Normal body temperature is maintained across environmental this is called homeostatic control variations through the regulation of heat production from metabolic activity €€mostly of the muscles and liver€ and heat dissipation from the skin and lungs.
- It is widely held that normal body temperature is 37.0°C €98.6°F€, but several studies have shown that average temperatures in healthy adults range from 30.0°C to 37.2€°C (86.0Â°Fâ€“99.0Â°F) with averages 36.4Â°C to 36.8Â°C €97.5Â°Fâ€“98.2Â°F€€ and 99th percentile 37.5Â°C to 37.7Â°C €€99.5Â°Fâ€“99.9Â°F)(1,2).
Temperature measurement in Fever
- How the temperature is taken can affect the result.
- Patients with temperatures between 38.9 and 41.0ºC can be assumed to have an infectious cause for their fever.
- Rectal temperature is considered the closest approximation to core temperature.
- Conventional means of measuring temperature in ICU patients include intravascular, intravesical, rectal, oral, cutaneous, and tympanic. Each has advantages and disadvantages
- €€Sublingual temperatures are felt much reliable, and generally measure 0.6€°C (1.0Â°F) lower than rectal temperatures.
- Whichever method is employed should be used consistently and the site of measurement documented.
- Axillary and tympanic measurements are less reliable, with axillary temperatures ranging from 0.25Â°C to 0.85Â°C (€€0.4Â°F1.5Â°F) lower than rectal measurements, and tympanic measurements ranging from 1.3Â°C (2.3Â°F) lower than rectal to 0.7Â°C (€1.3Â°F) higher (3,4).
Temperature variation —
- Normal body temperature varies by an average of 0.5Â°C (0.9€°F) throughout the day, with the lowest temperature early in the morning and peak in the mid afternoon.
- Other factors that influence normal body temperature include age, race, physical activity, postprandial state, pregnancy or ovulation, endocrine disorders, clothing, and ambient temperature and humidity. EvaluationA. History —
- A detailed history is essential to establishing the cause of fever.
The history should include the following components:
- • €€=Complete review of systems as well as past medical problems
- • €€=Previous surgeries, with attention to any implanted materials or devices
- • €€=Medications, supplements, and other drugs used
- • €€=Recent and remote travel
- • €€=Exposure to ill individuals
- • Exposure to animals or insects
- • €€=Occupation
- • €€=Ingestion of any questionable foods or substances
- • €€=Family history of unusual illnesses
Physical examination Fever —
- Careful physical examination should be performed.
- • Temperature and other vital signs should be measured very accurately.
- Heart rate, blood pressure, and respiratory rate normally increase in the face of fever. €€Bradycardia may be a sign of atypical infections.
- Hypotension may be a sign of systemic sepsis.
- • €€An examination of all organ systems and body areas should be performed, €€with emphasis given to the skin, lymphatics, heart, lungs, and nervous system.
- In addition, genital and rectal examinations should be performed regardless of gender.
Nausea is a subjective symptom disorders that also cause vomiting.
- Vomiting can result from the stimulation of four neurologic
- processes of Nausea and Vomiting — vagal and splanchnic fibers in the viscera, stimulated by distention,infection,or inflammatory irritation, vestibular system fibers mediated through muscarinic cholinergic and histamine H1 receptors, sounds, or emotions ,higher central nervous system (CNS) centers where sights, can trigger vomiting, .
- In brain their are chemoreceptor trigger zone within the brain that is rich in opioid, serotonergic, and dopamine receptors triggered by toxins, hypoxia, acidosis, radiation therapy, uremia, and chemotherapy
chart of nausia and vomiting
Nausea and Vomiting General Description —
- Vomiting is the active and forceful expulsion of gastric contents,
- Nausea is a â€œvague, intensely disagreeable sensation of sickness or â˜queasinessâ that may or may not be followed by vomiting and is distinguished from anorexiaâ€� €€== .
- A subjective unpleasant, wavelike sensation in the back of the throat, epigastrium, or abdomen that may or may not lead to the urge or need to vomit
Nausea and Vomiting Types –
- Periodic and recurring attacks of vomiting occurring in patients with a nervous temperament.
- Continued vomiting causes metabolic alkalosis as a result of chloride loss.
- Sudden unexplained attacks of gastroenteritis characterized by nausea, vomiting, and sometimes diarrhea.
- Although not proven, the symptoms are believed to be due to a virus. Treatment is symptomatic.
- The production of vomiting by administering certain types of emetics (e.g., syrup of ipecac or amorphine) or by physical stimulation of the posterior pharynx.
- Each person has the potential for this reaction to emotional stress, but the threshold varies from one person to another
- Occasional or persistent vomiting associated with severe emotional stress or brought on by the anticipation of stress.
vomiting of pregnancy
- The vomiting, esp. morning sickness, that some women experience during pregnancy.
chart of nausia and vomiting
Pathophysiology and Etiology with Epidemiology —
- Ejection through the mouth of the contents of the gastrointestinal tract.
- Along with diarrhea and hemorrhage, vomiting is an important potential cause of dehydration.
- It may result from toxins, drugs, uremia, and fevers; cerebral tumors; meningitis (often unaccompanied by nausea and failing to relieve associated headache); uterine or ovarian disease, irritation of the fauces, intestinal parasites, biliary colic; intestinal obstruction; diseases of the stomach such as ulcer, cancer, dysmotility, or dyspepsia; reflex from pregnancy, motion sickness; and neurological disorders such as migraine.
- Nausea and vomiting are common symptoms and frequently seen in outpatient, inpatient, and emergency settings.
Nausea and Vomiting Evaluation and History
- A thorough history should discuss sleep habits€€, the onset and frequency of vomiting, the symptoms of other family members, and the relationship to nausea and vomiting to meals or€€ types of food.
- A review of systems should specifically address associated anorexia, weight loss, abdominal pain, gastrointestinal €€symptoms, and neurologic symptoms€€. Vomiting prior to breakfast is more common in pregnancy, uremia,alcohol overuse, and increased intracranial pressure .
- Vomiting of undigested food one or more hours after meals should raise concern for gastric outlet obstruction or gastroparesis, whereas vomiting immediately after a meal is more common with psychogenic vomiting and bulimia.
- Many medications can induce nausea vomiting, including nonsteroidal anti-inflammatory drugs, opiates, anticonvulsants, antiparkinsonian agents,antibiotics, calcium channel blockers, nicotine, antiarrhythmics, alcohol, Beta-blockers, digoxin, chemotherapeutic agents
Physical examination of Nausea and Vomiting
- The abdominal exam should attempt to localize pain
- The physical examination should evaluate for acute dehydration and signs of infection.
- and evaluate for peptic ulcer disease, gallbladder disease, liver disease, or an acute abdomen.
- Barium radiography, an upper GI series, or abdominal computed tomography may be helpful in the diagnosis of gastric outlet obstruction gastroparesis .
- In severe acute or persistent vomiting, a flat and upright abdominal radiograph can help rule out GI obstruction or a perforated viscous.
- Concerns for intracranial lesions should prompt computed tomography or magnetic resonance imaging of the brain.
- Based on the clinical assessment, blood tests, liver function,hepatitis testing, amylase , pregnancy testing, or a metabolic profile may be appropriate. €€ For acute gastroenteritis that is not complicated by dehydration, laboratory tests are not necessary.
Nausea and Vomiting Diagnosis Differential diagnosis
- The diagnosis of acute nausea and vomiting can often be made on clinical history alone €€ Chronic symptoms may be more difficult to diagnose and may require laboratory and diagnostic testing. lists the differential diagnosis of nausea and vomiting.
Clinical manifestations Nausea and Vomiting
- Most patients with nausea and vomiting do not seek medical consultation and their disease is self-limiting ,
- Persistent or severe nausea and vomiting can lead to severe weight loss,
- hypokalemia and dehydration, or other electrolyte disturbances, and metabolic alkalosis .
Nausea and Vomiting Treatment:
- Antinausea medicines should be taken by mouth, rectally, intramuscularly or intravenously.
- Fluids may be given by mouth if the patient will accept them.
- If vomiting continues, intravenous fluids and electrolytes will be required to replace those lost in the vomit.
Postexertional malaise lasting >24 hours (1)
Fatigue is a very common complaint in the primary care office. It may be the primary cause for patient seeks care or a secondary complaint. We are all bothered by fatigue at some point . However, for maximmum of patients each year, it becomes bothersome enough to seek medical attention.€€ €€True fatigue needs to be distinguished from weakness and from excessive somnolence secondary to sleep disturbances€€. €€Fatigue lasting less than a month is considered acute. If symptoms last more than a month, €€fatigue is considered prolonged.
€€=fatigue Definitions €€==
Chronic fatigue is diagnosed when symptoms last &€€gt;€€6 months. The Center for Disease Control and Prevention has defined chronic fatigue syndrome €€€€ as profound fatigue of 6 months duration that presents with four of the following eight symptoms: Impairment in short-term mmory or concentration€€€€ Sore throat Tender lymphadenopathy€€ Myalgias Multijoint pain Headaches of a new type, pattern, or severity Unrefreshing €€sleep Idiopathic chronic fatigue is diagnosed if a patient has been fatigued for ox>6 months, but does not meet the other criteria for CFS.
€€==fatigue Testing Pathophysiology
. Etiology€€== Some of the common causes of CFS€€ . Fatigue may be due to medical disorders, or any psychiatric disease, or any lifestyle factors. In some cases, a cause is never determined. Fatigue that persists for several months or years is more likely to have a psychiatric etiology€€, whereas a shorter duration of fatigue is more likely to have a medical explanation If a medical cause of fatigue is present, it is usually identifiable on the initial history, physical and laboratory testing , €€Epidemiology€€The true incidence of profound fatigue is unknown. It has been estimated that over 7 million office visits per year are for complaints of fatigue €€The true gender predilection is also unknown, however, women present to the physician’s office twice as often as men. €€Patients younger than 45 years of age are more likely to present for fatigue than patients older than 45 years of age €€ €€Evaluation€€. History€€==A vast history and review of systems should be €€performed. The onset, duration, and degree of fatigue should be explored, along with any possible precipitating events. Specific attention should be given to sleep patterns, daytime somnolence, or €€sleep apnea symptoms. The patient’s exercise habits, caffeine intake€€, and drug or alcohol use should be explored, and medications should be reviewed. A psychiatric history to evaluate symptoms of depression or anxiety should be obtained. Lifestyle issues such as stress at home or in the work place, childcare responsibilities, shift work, or changing work schedules should be addressed. €€
Chronic fatigue Physical examination€€
A thorough physical examination should be performed. Vital signs should be carefully noted. Attention should be given to the presence of pallor, muscle weakness, goiter€€, lymphadenopathy, and body habitus. A psychiatric evaluation for signs of depression, anxiety€€, or other mental illness should be performed. In older adults, a mental status exam to evaluate cognitive function may be appropriate.
€€. fatigue Testing
Initial laboratory testing should be limited to: Complete blood count €€Comprehensive €€metabolic profile €€€€Thyroid-stimulating hormone €€Erythrocyte sedimentation rate
Other tests may be indicated by the history or physical examination:
Screening tests appropriate for age and gender should be performed.
Fatigue is a very commonly encountered complain€€t. In most cases, a thorough history, physical and a limited number of ancillary tests reveal a more precise diagnosis. Fatigue is rarely the only presenting symptom in cases of malignancy or connective tissue disease. Studies have shown that among patients with fatigue, approximately 40€€ have an underlying medical diagnosis, approximately 40€€ have a psychiatric diagnosis, and 12€€ have both medical and psychiatric explanations for their fatigue. Approximately 8€€ of patients have no discernible diagnosis €€ If undiagnosed fatigue persists for &€€gt;6 months and meets the other criteria for CFS, that diagnosis is applied. If the other criteria for CFS are not met, the term idiopathic chronic fatigue is used. Fatigue that cannot be attributed to a medical or psychiatric diagnosis is often thought to be due to lifestyle factors.