For this reason, in general, additional tests are required to establish the diagnosis. Each of these features can help focus the differential diagnosis see figure 151, table 151. Chest pain pediatrics clerkship the university of chicago. Differential diagnosis of pulmonary embolism in outpatients with nonspecific cardiopulmonary symptoms article pdf available in internal and emergency medicine 88 november 2011 with 368 reads. Chest pain covered extensively in chapter 9 is another pivotal clue in patients with dyspnea. Angiogram demonstrated no significant coronary artery disease. If this is not available locally, the patient should be referred to cardiology services. A case series of 181 adults with clinically suspected the differential diagnosis includes other conditions with similar symptoms and signs, cocaine. Mohit bhasin md, facc norfolk, va american college of.
Chest pain differential diagnosis linkedin slideshare. Chest pain is the presenting complaint in over 6 million emergency department visits each year. In the uk, 1% to 2% of adults attend primary care each year with a new presentation of chest pain. This causes shortness of breath, coughing, chest pain, and wheezing, similar to asthma. Pulmonary embolism is the most common serious cause, found in. However, when we speak of chest pain, the reason behind the same need not be something temporary. The differential diagnosis of chest pain can be divided broadly into. Identifying emergency department patients with chest pain who. Annually, physicians evaluate 600,000 cases of chest pain in patients aged 1021 years, a number that may reflect overwhelming concern about chest pain as a manifestation of cardiac disease as noted in older patients. Oshea and others published differential diagnosis of chest pain find, read and cite all the research you need on. Syncope and vomiting may also be associated with aaa. Evaluation of chest pain differential diagnosis of.
Differential diagnosis of low back pain article pdf available in seminars in pain medicine 23. Chest pain with features of angina pectoris this patients description of dull, aching, exertion related substernal chest pain is suggestive of ischemic cardiac origin. Specific arrhythmias may be overread or not accurately diag nosed. Value and limitations of chest pain history in the evaluation of. The quest to rule out other causes of asthmalike symptoms, or to rule in asthma as the likely cause, is called differential diagnosis. It can be divided into heartrelated and nonheartrelated pain. Evaluation of patients with chest painwith chest pain. Chest pain is a common reason parents seek medical attention for their children. Her findings of a fh of early ascvd, hypertension, and early surgical menopause are pertinent risk factors for development. To understand the differential diagnosis of chest pain requiring cardiac surgical consultation. Epidemiology of chest pain reflects selection bias.
Churchills pocketbook of differential diagnosis pdf 4th. See evaluation of the adult with chest pain in the emergency department. Chest pain is pain or discomfort in the chest, typically the front of the chest. An expert algorithm to assist in the diagnosis of chest pain can be found here to go back to the main page on unstable angina, click here overview. Chest pain knowledge for medical students and physicians. Differential diagnosis of chest pain request pdf researchgate. This refers to chest pain that is not sharp and is not the patients familiar angina. Jun 06, 2016 no more chest pain today is the 4th day, he is febrile 38 39c since 3rd day, esr and wbc is high, he suddenly complaining of severe sharp precordial pain, cannot breathin or cannot lie down. Ideally, the detailed history is taken where resuscitation facilities are available. Although the differential diagnosis of chest pain is exhaustive, chest pain in children is least likely to be cardiac in. Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling. Esophageal disorders of the esophagus mimics chest pain from a heart attack. The patient needs to be assessed at a rapid access chest pain clinic. Although the differential diagnosis of chest pain is exhaustive, chest pain in children is.
Acute chest pain of nontraumatic origin is a common reason for presentation to physicians offices and emergency rooms. Prospective multicenter evaluation of cocaineassociated chest pain. The younger the patient, the more likely an organic etiology will be found although there is rarely a serious underlying disease. If the chest pain has any of the features listed above, other causes of chest pain such as gastrointestinal disease or musculoskeletal pain should be considered.
Nov 06, 2015 acute chest pain of nontraumatic origin is a common reason for presentation to physicians offices and emergency rooms. In particular, aaa might be considered in the differential diagnosis of an older patient with symptoms suggestive of renal colic. Some patients presenting with chest pain will have serious acute illness with a high short. Because acute chest pain, depending on its etiology, may be associated with a high risk of death, rapid, goaloriented management is mandatory. White massachusetts general hospital the differential diagnosis of chest pain pain in the chest may be a manifestation of many widely differing disease processes. History of exertional chest pain or exertional syncope. This article describes the causes, assessment and differential diagnosis of musculoskeletal chest wall pain, and the management of its most common causes. Sep 01, 2018 hollander je, hoffman rs, gennis p, et al. A electrocardiogram ecg of a 58yearold woman presenting abdominal pain and vomiting, who, while in the emergency department developed chest pain and subsequent positive troponins. Differential dx strategies university of massachusetts. Pain due to insufficient blood flow to the heart is also. The differential diagnosis is extensive and includes diagnoses that can be.
Outpatient chest pain up to 16% of outpatient chest pain evaluations may never reach a definitive diagnosis. Evaluation of chest pain differential diagnosis of symptoms. Acute intoxication view in chinese also present as chest pain following cocaine abuse. Chest pain that is reproducible during the physical exam with contact of the chest wall is more indicative of noncardiac chest pain, but still cannot completely rule out acute coronary syndrome. Differential diagnosis of chest pain pain is a common health condition, and is usually temporary in nature. A thorough history and physical examination will help differentiate a serious cause from a. Associated symptoms may include pain in the shoulder, arm, upper abdomen or jaw or nausea, sweating or shortness of breath. Before ordering a test elicit patients fears false negative stress testing, invasive procedures, expectations resume exercise with confidence, and define a successful chest pain workup together. Once the clinical examination has narrowed the differential diagnosis, diagnostic testing helps determine whether the patient has a serious. Substernal or epigastric positional lying down may follow a meal gastroesophageal reflux disease, or gerd occurs when acidic digestive juices flow backward from the stomach into the esophagus. Chest pain david ponka, md and michael kirlew, md dr ponka is an assistant professor and dr kirlew is a secondyear resident in the department of family medicine at the university of ottawa in ontario. Differential diagnosis of pulmonary embolism in outpatients with nonspecific cardiopulmonary symptoms article pdf available in internal and emergency medicine 88. Furthermore, within the consideration of lifethreatening causes, patients may be suffering from coronary causes, as well as pulmonary embolism.
In rosens emergency medicine concepts and clinical practice 8th ed. A patient with persistent symptoms may warrant a new evaluation. In clinical practice, there is an accumulated body of evidence that outpatient ecgs should be stored or transmitted to a. Churchills pocketbook of differential diagnosis is the best differential diagnosis book for medical students who are working or are looking forward to more of the clinical approach to the field. When this happens in adults, it usually occurs in those with neurological disorders, parkinsons disease, strokes, the mentally challenged, airway or esophagus abnormalities, the elderly, or. In fact, more than 45% of pediatric chest pain cases elude definitive diagnosis. Chest pain that radiates to the back, jaw, left arm or left shoulder. Uncommon differential diagnoses and potential complications table 6 uncommon differential diagnosis for abdominal pain medical condition relevant findings and potential complications gastrointestinal intussusception colicky pain, flexing of legs, fever, lethargy, vomiting, peak incidence in children at. There are several lifethreatening causes of chest pain which need to be evaluated for first, which include. Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. Nontraumatic chest pain is one of the most common causes of emergency department visits and is common in both inpatients and outpatients. Chest pain is a common pediatric complaint with the average presenting age of 12. Hopewell case 2 differential diagnosis of tb 2 case 2. In brief, common causes of dyspnea and pleuritic chest pain are pneumonia, pe.
Outpatient diagnosis of acute chest pain in adults american. Chest pain is something that cannot be neglected under any circumstances whatsoever. The interdisciplinary management of acute chest pain. Chest pain whether in the office ed or inpatient settingwhether in the office, ed, or inpatient setting, the patient with chest pain presents a diagnostic dilemma you can not treat all patients with chest pain the same due to the broad differential diagnosis that ranges from benign causes to. Treatment response treatment begun with ripe sputum culture grew m. Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several lifethreatening causes. This article throws light on some possible diagnosis. Left ventriculogram demonstrated distal anterior and apical hypokinesis. It is the presenting complaint in 1% of officebased visits. Coronary heart disease is the cause in up to 25% of cases. Cause grouping differentials classical history classic examination findings investigation findings initial test, diagnostic test. Diagnosing the cause of chest pain american family physician. The initial pivotal points are the acuity of onset of the pain and the presence of vital sign abnormalities. Aug 20, 2018 chest pain is a common reason parents seek medical attention for their children.
Patients may call chest symptoms pressure, discomfort, tightness, funny feeling, etc. Although the differential diagnosis of chest pain is exhaustive, chest pain in children is least likely to be cardiac in origin. Differential diagnosis for chest pain oxford medical education. It may be described as sharp, dull, pressure, heaviness or squeezing.
In other situations where immediate admission may not be indicated, a full. Differential diagnosis of chest pain is generated almost entirely by history, with some addition of exg, chest xray, and specific laboratory exams. As appropriate, alternative diagnoses including the. Christopher cheung approach to pediatric abdominal. The differential diagnosis of chest pain syndrome is broad and disparate, including disease processes that range from nonurgent to life threatening. The differential diagnosis of chest pain sciencedirect.
Approach to undifferentiated chest pain in the emergency. Differentiating acute coronary syndrome acs from other, noncardiac causes of chest pain is imperative in emergency practice. Common and important causes of chest pain for doctors and medical students. Assessment of chest pain differential diagnosis of symptoms. Chest pain is a common chief complaint, accounting for approximately 5% of all emergency department visits in the us per year. Coronary syndrome acs or other lifethreatening emergencies suspected. Distinguishing whether a patient presenting with chest pain has acs or a non acs problem is at best difficult. The differential diagnosis of chest pain is broad and. The differential diagnosis is extensive and includes diagnoses that can be imminently lifethreatening. Evaluation of chest pain in 2019 american college of physicians. Assessment of chest pain differential diagnosis of. Management of palpitations in urgent care automated readings in ecg machines use builtin software that does not always provide an accurate diagnosis.
If its not asthma, thats important to know, because the strategy for obtaining ideal control of your symptoms is likely to be different than the strategy for. It is the presenting complaint in 1% of clinicbased visits. The evaluation of chest pain in the emergency department is discussed elsewhere. Populationbased questionnaire studies show about 20% of adults reporting. Mi myocardial infarction occurs when blood supply to the myocardium via coronary. Nov 15, 2005 once the clinical examination has narrowed the differential diagnosis, diagnostic testing helps determine whether the patient has a serious condition. Differential diagnosis for abdominal pain based on history and physical examination in spite of the fact that area of stomach pain or abdominal pain directs the underlying assessment, related signs and indications are prescient of certain reasons for pain in the abdomen and can limit the differential diagnosis. Chest pain may be pleuritic or nonpleuritic and acute or chronicrecurrent. The differential diagnosis is broad and includes cardiac e. Chest pain cardiac or not treat patient as though he is critical until proved otherwise history risk factors, ho ihd, previous rxs, previous chest pain pain heart burn burning. Feb 01, 20 outpatient diagnosis of acute chest pain in adults this is a corrected version of the article that appeared in print.
Pulmonary embolism patients typically present with. Chest pain may be caused by either benign or lifethreatening etiologies and is usually divided into cardiac. A patient with chest pain poses one of the most complicated diagnostic challenges. Differential diagnosis for chest pain oxford medical.
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