Chest Pain- Differential Diagnosis

Cardiac or Non Cardiac Chest pain: Assessment and identification is very important for the nurse .

1. Getting to the root of Chest P ain Differential Diagnosis Cardiac & Non Cardiac By: Ms. Shanta Peter 1

2. Chest Pain-- cardiac or Not Treat patient as though he is critical --- until proved otherwise History R isk factors, H/O IHD, previous Rxs , Previous chest pain Pain- Heart burn - burning sensation – chest pain with pressure / tightness Remember --- – …………… treat with cause … there are many causes 2

3. Accuracy of Chest Pain Diagnosis Using the History and Physical Examination   Determining whether pain is Sub-sternal , P rovoked by exertion R elieved by rest or nitroglycerin helps to clarify whether it is …………………… Typical anginal pain ( has all 3 characteristics ) Atypical anginal pain ( has 2 characteristics Nonanginal pain (has 1 characteristic). 3

4. Common Causes of Chest Pain Aortic Esophageal/GI Lungs & Pleura Musculo -Skeletal Neurological Psychological/ others Aortic dissection, Aortic aneurism Esophagitis, Esop . Spasm , esophageal tear Pancreatitis, Biliary /GB disease , GERD, Peptic Ulcer Bronchospasm, PE, Pneumonia ,TB, Trachitis , Pleuritis , PneumThorax , Malignancy , Asthma. Ost . Arthritis, Rib#, I. Costal Muscle injury, Costochondritis , Cerv . Disc Disease Prolapsed disc, Herpez Zoster, Thoracic Outlet Syndrome Panic Attack/Anxiety Disorders , Cocaine abuse 4

5. Chest Pain That Can Kill …. Acute Coronary – Syndrome Pulmonary- Embolism Aortic- Dissection Esophageal Rupture Pneumothorax Pneumonia 5

6. Sudden & Instantaneous Chest Pain Tension Pneumthorax Spontaneous Open Pulm . Embolism DVT, Obesity, Pregnancy, Prolonged immobilization, CHF …. 6

7. Pneumothorax 7

8. Pneumothorax Sharp C. Pain. Dyspnea ,absence of breath- sound in the affected side Radionuclide studies – Gated pool SPECT – Single proton emission computed Tomography PET – Positron Emission Tomography Pulm . Embolism Sudden pleuretic substernal pain with dyspnea , T cardia , fever or cough , diaphoresis – mimic MI/angina VQ Scan D DIMER Spiral CT-- best Diag – (Pneumonia ) 8

9. Pneumonia Infection of pulm . tissue – Interstitial spaces, alveoli, bronchioles Chest pain – pleuritic , come sin suddenly Febrile – chills , cough with copious/blood stained sputum Rales --- rhonchi wheezes Hypoxia ( Ca ) 9

10. Sub sternal – epi -gastric Chest Pain intensified with swallowing 10

11. 11 Pan . C Cys.G U,DU

12. G Intestinal P ancreatitis : Pain in the LUQ, substernal . Radiate to back , difficulty in breathing, tachycardia, vomiting, worse in supine , better while leaning forward Cholecystitis : Pain in RUQ – precipitate by meal Gastric Ulcer Pain Lt Epigastrium – radiation to back Duodinal Ulcer Mid Epigastric pain – cramping- 2-4 hrs after meal (E rupture ) 12

13. Esophageal Rupture Mallory–Weiss syndrome   Sudden severe C . Pain – followed by vomiting, or UGI tract procedure CXR: ( early )shows mediastinal or free peritoneal air Hours to days later : widening of mediastinum, pleural effusion   13

14. Coronary Arteries 14

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16. 16 H .Disease begins when cholesterol, fatty material & Ca deposit in the arteries. Atherosclerosis

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19. Cardiac Chest Pain Dissecting Aortic aneurisms Cardiac Tamponade * Heart Failure Peri / endo /myocarditis Cardiogenic shock MVP / M.stenosis Acute Coronary Syndromes *Myocardial Ischemia * Stable Angina *Unstable Angina *Myocardial Infarction *Pericarditis 19

20. ANGINA PECTORIS . Myocardial ischemia Expected companion of IHD ……. 20

21. Accuracy of Chest Pain Diagnosis Using the History and Physical Examination   Determining whether pain is Sub-sternal , P rovoked by exertion R elieved by rest or nitroglycerin helps to clarify whether it is …………………… Typical anginal pain ( has all 3 characteristics ) Atypical anginal pain ( has 2 characteristics Non- anginal pain (has 1 characteristic). 21

22. Levine’s sign 22

23. 23 S Ang

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25. Angina .. Myocardial ischemia Stable Angina ( Exertional Angina )Stable pattern of onset ……………… relieved by Rest/GTN B. Unstable Angina ( PreinfarctionAngina ) unpredictable, NOT relieved by GTN C. Variant Angina ( Prinzmetal - vasospastic ) , without relation to effort , Occur at REST- between midnight & early morning ST Elevation --- 25

26. D . Intractable Angina – Chronic , incapacitating, unresponsive to treatment E. Pre-infarction Angina ( Last more than 15 mts ) F. Post infarction Angina ( after MI ,residual ischemia) 26

27. PERICARDITIS 27

28. Pericarditis Sharp Pre-cordial pain, deep and diffuse Worse in supine position- relieved while leaning fore ward Aggravated during inspiration coughing H/O viral infection , MI……. 28

29. 29 TAA

30. T. Aortic Dissection of Aneurism Blood violates aortic intimal and adventitial layers False lumen is created Dissection may extend proximally, distally, or in both directions 30

31. T.A Aneurism dissection Constant and boring chest pain Deep diffuse – in supine position Cough, dyspnea, stridor Aphonia ( loss of voice) -- 31

32. H Attack signs in Women Pain or discomfort in one or both arms, the back, neck, jaw or stomach. Shortness of breath with or without chest discomfort. breaking out in a cold sweat, nausea or lightheadedness. As with men, women’s most common heart attack symptom is chest pain or Chest dis comfort, other common symptoms, particularly shortness of breath, nausea/vomiting and back or jaw pain . 32

33. Complications Cardiac arrest ---------------------- 33

34. 34 Possible Factors -6Hs & 5Ts cardiac arrest Hypovolemea Hypoxia Hypothermia Hypoglycemia Hypo- Hyperkalemia Hydrogen ion ( Acidosis ) Toxins Trauma Thrombosis ( coronary- pulmonary) Tension pneumothorax

35. 21 yrs old young male – was lifting weights –in the GIM . He had sudden onset of sharp chest pain, and SOB … Brought him to ER … HR 122. RR 34, BP 70/? Sat 88% Decreased breath sounds on left side of the chest .. ??????? 35

36. Mr. Mohd in CCU with Ext Ant MI, complicated with vent arrhythmia treatments are continuing. No more chest pain Today is the 4 th day , he is febrile 38- 39C since 3 rd day , ESR and WBC is high, He suddenly complaining of severe sharp precordial pain, cannot breath-in or cannot lie down. He is bending down his chest and crying 36

37. Ms .A 61yrs,had severe Asthmatic attack ,as the O2 sat was 89% . Put on Mech Ventilator Mode : PEEP . 3 rd day sedations stopped and started to wean her. Suddenly she screamed of severe chest pain and dyspnea What will be the possible condition ? 37

38. OPD – Endoscopy room Ms K had gastroscopy ? D.Ulcer , she is in the recovery room after the procedure. BP and other vital signs stable. She is coming out of the sedation . Suddenly she is complaining of pain holding her chest , breathless. ??????? 38