1. CHEST PAIN Pulmonary Medicine Department Ain Shams University http://telemed.shams.edu.eg/moodle5

2. Page  2 Contents: Causes Types & Character AnalysisDiagnosisQuiz

3. Page  3 Causes of Chest Pain CardiacNon-Cardiac

4. Page  4 Causes of Chest Pain Chest Wall Diseases: Chest Wall Diseases: Muscular strain. Intercostal myositis. Thoracic Herpes Zoster. Intercostal nerve infiltration. Rib fracture. Rib tumors (1ry or metastatic). Pleural Diseases: Pleural Diseases:Pleurisy.Pneumothorax. Pleural effusion. Mesothelioma. Metastatic tumors. Mediastinal Causes: Mediastinal Causes: Cardiac ischemia & MI. Oesophagitis.Pericarditis.Mediastinitis. Aortic dissection. Thymoma. Retrosternal goitre. Mediastinal LDN Airway & Lung Causes: Airway & Lung Causes:Tracheitis.Pneumonia Endotracheal intubation. Central bronchial carcinoma.

5. Page  5 Cardiac & Non-Cardiac Chest Pain

6. Page  6 Causes of Acute Chest Pain: Coronary artery disease Coronary artery disease Pulmonary embolism/infarction Pulmonary embolism/infarction Pneumothorax Pneumothorax Pleurisy/ Pericarditis Pleurisy/ Pericarditis Dissecting aortic aneurysm Dissecting aortic aneurysm Esophageal spasm Esophageal spasm

7. Page  7 Types & Character of Chest Pain: Tracheal pain: retrosternal, burning, ↑ by coughing. Pleural pain: stitching, stabbing (or) dull aching, ↑ with coughing & inspiration, ↓ by holding breath & associated with suppressed cough & dyspnea. Cardiac pain: retrosternal compressing radiating to the left shoulder, neck & epigastruim. Pericardial pain: retrosternal, stabbing, ↑ by deep breathing & swallowing, ↓ by sitting & leaning forward. Aortic pain: severe, sharp stabbing, interscapular (or) anterior chest, & radiating to the interscapular area. Reflux pain: retrosternal & epigastric, burning, ↑ after meals.

8. Page  8 Analysis of Chest Pain: OnsetCourseDuration Character: stitching, stabbing, sawing (or) burning. Site Radiation (or) Referral What ↑ & what ↓ Severity: Interfering with daily activity (or) sleep rhythm. Associated symptom History of trauma (or) surgery

9. Page  9 Diagnosis of Chest Pain: History: History: Onset & duration. Associated risk factor for ischemic heart disease e.g. smoking, hyperlipidaemia, strong family history, hypertension, diabetes (if MI or angina are suspected). History of recent immobilization (if pulmonary embolism is suspected). History of hypertension (if aortic dissection is suspected). History of hemoptysis (if pulmonary embolism is suspected). History of smoking or lifting heavy objects (if pneumothorax is suspected).

10. Page  10 Examination: Examination: Diminished air entry & hyperresonance (if pneumothorax is suspected). Swollen tender calf muscles (if pulmonary embolism is suspected). Pleural friction rub (if pleurisy is suspected). Pericardial friction rub (if pericarditis is suspected). Early diastolic murmur of AI (if aortic dissection is suspected). Diminished air entry & dullness (if pleural effusion is suspected). Bronchial breathing & fixed crepitations (if pneumonia is suspected). Diagnosis of Chest Pain:

11. Page  11 Investigations: Investigations: Chest X ray (if pneumothorax, pleural effusion, pulmonary infarction, pneumomediatinum, pneumonia or fracture ribs are suspected). Dopplex (if pulmonary embolism is suspected). ABGs (if pulmonary embolism is suspected). Complete blood picture & sputum work up (if pneumonia is suspected). Echo cardiography & spiral CT scan for chest & abdomen (if aortic dissection is suspected). ECG, cardiac enzymes & cardiac troponin-T (if MI or unstable angina are suspected). Amylase level (if rupture esophagus is suspected). Diagnosis of Chest Pain:

12. Page  12 24 Years old male presented to the ER with chest pain in the right hemithorax, acute onset followed by dyspnea at rest not associated with orthopnea or PND. On examination: diminished breath sounds over the right hemithorax. Routine lab. Investigations were normal. ECG was done. CXR was done. Quiz What is your diagnosis? What is your management?

13. Page  13 56 Years old female presented to the ER with retrosternal stabbing chest pain, acute onset along with dyspnea at rest not associated with orthopnea or PND. On examination: epigastric tenderness. Routine lab. Investigations were normal. ECG was done. CXR was done. Quiz What is your diagnosis? What is your management?

14. Page  14 75 Years old male with CVS presented to the ER with recurrent right sided stitching chest pain, acute onset, resolved spontaneously without treatment, along with dyspnea at rest not associated with orthopnea or PND. On examination: NAD History prolonged recumbancy. ECG was done. CXR was done. Quiz What is your diagnosis? What is your management?

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