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Chest Pain- Differential Diagnosis
1. Getting to the root of Chest Pain
Differential Diagnosis
Cardiac & Non Cardiac
By: Ms. Shanta Peter
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2. Chest Pain-- cardiac or Not
• Treat patient as though he is critical --- until
proved otherwise
History
• Risk 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
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3. Accuracy of Chest Pain Diagnosis Using the History
and Physical Examination
Determining whether pain is
• Sub-sternal,
• Provoked by exertion
• Relieved by rest or nitroglycerin
helps to clarify whether it is ……………………
1. Typical anginal pain (has all 3characteristics)
2. Atypical anginal pain (has 2 characteristics
3. Nonanginal pain (has 1 characteristic).
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12. G Intestinal
Pancreatitis : 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
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21. Accuracy of Chest Pain Diagnosis Using the History
and Physical Examination
Determining whether pain is
• Sub-sternal,
• Provoked by exertion
• Relieved by rest or nitroglycerin
helps to clarify whether it is ……………………
1. Typical anginal pain (has all 3characteristics)
2. Atypical anginal pain (has 2 characteristics
3. Non-anginal pain (has 1 characteristic).
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25. Angina ..Myocardial ischemia
A. 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 ---
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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)
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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
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31. T.A Aneurism dissection
• Constant and boring chest pain
• Deep diffuse – in supine position
• Cough, dyspnea, stridor
• Aphonia ( loss of voice) --
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32. H Attack signs in Women
1. Pain or discomfort in one or both arms, the back,
neck, jaw or stomach.
2. Shortness of breath with or without chest
discomfort.
3. breaking out in a cold sweat, nausea or
lightheadedness.
4. 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.
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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 .. ???????
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36. • Mr. Mohd in CCU with Ext Ant MI,
complicated with vent arrhythmia
treatments are continuing. 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 breath-in or cannot
lie down. He is bending down his chest and
crying
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37. • Ms .A 61yrs,had severe Asthmatic attack ,as
the O2 sat was 89% . Put on Mech Ventilator
Mode : PEEP .
• 3rd day sedations stopped and started to
wean her. Suddenly she screamed of severe
chest pain and dyspnea
What will be the possible condition ?
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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.
???????
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