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1. Chest Pain
Chest pain is a common cause for admission to hospital. Taking a clear history is essential in making the correct
diagnosis. Different diseases present with different types of chest pain.
Pneumothorax.
Pneumonia.
Pulmonary embolus (PE).
Pericarditis: retrosternal.
Bornholm disease (Coxsackie B unilateral infection of respiratory muscles).
Angina: crushing.
Myocardial infarction (MI): crushing.
Dissecting aortic aneurysm: tearing interscapular pain.
Esophagitis: burning.
Esophageal spasm.
Esophageal tear (Boerrhave's syndrome).
Rib fracture.
Shingles (herpes zoster): pain precedes rash.
Costochondritis (Tietze's syndrome).
Nerve root compression.
Dyspnea: pulmonary embolism, pneumonia, pneumothorax, pulmonary edema in cardiac ischemia, hyperventilation in
anxiety.
Cough: purulent sputum in pneumonia, hemoptysis in pulmonary embolism, frothy pink sputum in pulmonary edema.
Rigors: pneumonia (particularly lobar pneumonia).
Calf swelling: has PE arisen from deep vein thrombosis? Bilateral swelling suggests heart failure.
Palpitations: arrhythmia can cause angina or result from cardiac ischemia, PE, or pneumonia.
Clamminess, nausea, vomiting, and sweating are features of myocardial infarction or massive pulmonary embolism.
Do not forget about anginal equivalents, such as those listed above, or jaw pain/tightness or indigestion. Anginal
equivalents may be the only presenting symptoms of an MI, especially in elderly and diabetic patients. When in doubt,
get an ECG and cardiac enzymes.
Ischemic heart disease: smoking, family history, cholesterol, hypertension, diabetes, male sex, age over 50
years.
PE: recent travel, immobility, or surgery, family history, pregnancy, malignancy.
Pneumothorax: spontaneous (young, thin men), trauma, emphysema, asthma, malignancy, staphylococcal
pneumonia, cystic fibrosis.
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Also look for signs of venous stasis and arterial insufficiency in the lower extremities. Is there a brown discoloration (hemosiderin staining due to blood
pooling) of the ankles? Does the patient have palpable lower extremity pulses.
All patients with chest pain should have an electrocardiogram (ECG), chest x-ray (CXR), and cardiac enzymes (see Fig.
1.5). Further investigation will be directed by findings in these tests in conjunction with the history and clinical
examination. An algorithm for the investigation of the patient with chest pain is given in Fig. 1.2.
Electrocardiogram
ST depression and elevation (Fig. 1.3) on ECG are suggestive of myocardial ischemia and acute MI, respectively. Changes
suggestive of PE are shown in Fig. 1.4. Arrhythmia may also be detected on ECG.
Chest x-ray
Pneumothorax, consolidation (pneumonia, PE), widened mediastinum (aortic dissection), pulmonary edema
(myocardial ischemia/infarction) and fractured ribs may be detected on CXR.
Cardiac enzymes
Serial cardiac enzymes should be assessed every 8 hours for 24 hours if MI is considered (see Fig. 1.5).
Stress test
An exercise test may be diagnostic when angina is suspected. Patients walk, ride a bike, or receive medication to
increase the heart rate. These tests are done in conjunction with ECG monitoring, and a rest and stressed
echocardiogram may also be used during this exam. Any sign of ischemia, such as ST elevation/depression, a drop in
blood pressure, chest pain, or arrhythmia, is grounds for stopping the exam. Of note, exercise stress tests with ECG
monitoring have a high false-negative rate in women. Therefore, it is often advantageous for a female patient either to
undergo a nuclear medicine test, such as an adenosine/thallium stress test, or to go directly to catheterization. In the
adenosine/thallium stress test, the heart is medically stressed and a radiolabeled tracer (thallium or sestimibi) is
introduced to detect areas of low flow during stressed conditions.
Coronary angiography
Coronary angiography allows direct visualization of the coronary arterial tree. It should be used in severe
angina to determine whether angioplasty or coronary artery bypass grafting might be beneficial.
Angiography is becoming more and more common as the number of centers with interventional cardiologists
increases. Patients with equivocal or positive findings on exercise stress tests, along with those who have
"good stories" (i.e., risk factors for coronary artery disease) are taken to catheterization regularly.
Patients should undergo catheterization if they have two of the following three characteristics:
Ventilation-perfusion scan
Ventilation-perfusion scan is used to diagnose PE. In some circumstances (e.g., when there is pre-existing
obstructive airways disease) interpretation of this test can be difficult, so pulmonary angiography should
then be performed. PE protocol CT can be used in addition to angiography in evaluating the patient with
pre-existing pulmonary disease.
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Echocardiogram
The presence of a dissecting aortic aneurysm should be confirmed by urgent echocardiography
(particularly transesophageal echocardiography) or by computed tomography scan. Urgent
echocardiography is now used to help detect cardiac effusions and tamponade. Echocardiography also can
be used to assess for possible sequelae of MI, such as myocardial dyskinesia, papillary rupture, or
ventricular thrombus.
Figure 1.2 Algorithm for the investigation of the patient with chest pain.