UTHCT 1 Chest Pain: Diagnostic Challenges Jose R Jimenez M.D. Family Medicine Dept. U.T. Health Center at Tyler

2UTHCT Objectives Help the Family Physician sharpen their diagnostic skills Help the Family Physician sharpen their diagnostic skills Broaden the Differential Diagnosis Broaden the Differential Diagnosis Evaluation Pearls and Pitfalls Evaluation Pearls and Pitfalls

3UTHCT Clinic Presentation: History Points Pain duration, intensity, nature, location Pain duration, intensity, nature, location Referred pain Referred pain Associated symptoms Associated symptoms EF – AF EF – AF Hx Caveats  DM (T I, T II), Geriatric Hx Caveats  DM (T I, T II), Geriatric

4UTHCT ROS Recent changes in aerobic capacity Recent changes in aerobic capacity Recurrent vague symptoms with exhertion Recurrent vague symptoms with exhertion

5UTHCT Risk Factor Eval Soc. Hx. Soc. Hx. Fam. Hx Fam. Hx Past Med Hx (old Records) Past Med Hx (old Records)

6UTHCT Physical Exam Points Primary Survey, Secondary Survey Primary Survey, Secondary Survey VS- HR, BP, pOX VS- HR, BP, pOX Neck, Chest, Abdomen, Extremities Neck, Chest, Abdomen, Extremities

7UTHCT Diagnostic Testing ECG ECG Lab Lab Cxr Cxr CT CT Eval. Caveats: s.l.ntg., GI cocktail, NSAID’s Eval. Caveats: s.l.ntg., GI cocktail, NSAID’s

8UTHCT Differential Diagnosis Potentially unstable pathology Potentially unstable pathology Others Others

9UTHCT Pressing Diagnoses Cardiac  AMI/ACS Cardiac  AMI/ACS Vascular  Aortic Dis. Vascular  Aortic Dis. Pulmonary  PE, Pneumothorax Pulmonary  PE, Pneumothorax Pericarditis/Tamponade Pericarditis/Tamponade Esophageal Rupture (Boerhaave syndrome) Esophageal Rupture (Boerhaave syndrome)

10UTHCT Other Diagnoses Cardiac  Myocardium/ACS  Valvular HD – AS, AI, MVP  Valvular HD – AS, AI, MVP  Pericarditis  Pericarditis Pulmonary  PE/ Infarction  Infectious  Infectious  Neoplastic  Neoplastic

11UTHCT Other Diagnoses (cont.) Esophageal  GERD, Motility Esophageal  GERD, Motility Rheumatic/Orthopedic  Costochondritis, Fibromyalgia, OA, RA, Vertebral/Disc Disease Rheumatic/Orthopedic  Costochondritis, Fibromyalgia, OA, RA, Vertebral/Disc Disease

12UTHCT Other Dx. (cont.) Psychiatric  Gen. Anxiety Disorder, Panic Disorder, Agoraphobia, Depression, Somatization disorders. Psychiatric  Gen. Anxiety Disorder, Panic Disorder, Agoraphobia, Depression, Somatization disorders. Misc.  Shingles, PUD, Pancreatitis, Drugs (cocaine,crack). Misc.  Shingles, PUD, Pancreatitis, Drugs (cocaine,crack).

13UTHCT Chest Pain  Diagnosis Avoid Pitfalls, avoid narrowing the differential diagnosis list prematurely Avoid Pitfalls, avoid narrowing the differential diagnosis list prematurely Think “Outside the Box”, keep the differential Dx. Broad, Think “Outside the Box”, keep the differential Dx. Broad, Reasses pt. Reasses pt. Repeat poor studies Repeat poor studies Repeat good studies prn. Repeat good studies prn. Look closely at the Cxr, consider CT Look closely at the Cxr, consider CT

14UTHCT Conclusion We all get burned, but we stay in the kitchen We all get burned, but we stay in the kitchen Q & A Q & A

UTHCT 15 References Emergency Medicine: A comprehensive Study Guide, 5 th Ed., Judith E. Tintinalli, Editor. Diagnosis of Acute Coronary Syndrome, American Family Physician, July 2005, S. Achar Evaluation of the patient with acute chest pain, NEJM Vol.342, No.16, p.1187, 2000, Review