Diagnosis Wikidoc: Chest Pain no ST elevation

• Supportive symptoms and signs include the following:

  • Back pain in 67% of cases
  • Diminution or absence of pulses in 40% of case
  • Coma, altered mental status, Cerebrovascular accident (CVA) and vagal episodes are seen in up to 20%
  • Descending dissection can lead to splanchnic ischemia, renal insufficiency, lower extremity ischemia or pulse deficits or focal neurologic deficits due to spinal cord ischemia.

• Chest X-Ray Abnormalities Include:

  • An increased aortic diameter is the most common CXR finding, seen in up to 84% of patients.
  • A widened mediastinum is the next most common finding, seen in 15-20%.
  • Normal in 17%.
  • Pleural effusion (hemothorax) in the absence of CHF can also be another clue to dissection.

• Next Study to Do:

  • MRI is currently thought to be the most sensitive noninvasive method of making the diagnosis of aortic dissection. As with CT, the diagnosis is made upon visualization of a double lumen with a visible flap. Sensitivity and specificity are both thought to be 98%, and the site of entry can be visualized in 85% of cases.

• Supportive symptoms include:

  • Shortness of breath
  • Chest pain
  • Dyspnea
  • Anxiety
  • Pleuritic chest pain

• Supportive laboratory studies include:

  • D-dimers are formed by the degradation of fibrin clot.
  • Almost all patients with PE have some endogenous fibrinolysis, and therefore have elevated levels of D-dimer.
  • Many other processes, such as pneumonia, congestive heart failure (CHF), myocardial infarction (MI), malignancy, and surgery, are also associated with a mild degree of fibrinolysis, and hence an elevated D-dimer is not specific for pulmonary embolism.
  • Its negative predictive value, however, is 91 – 94%

• Next study to do:

  • Spiral CT scanning is now a standard modality to non-invasively diagnose PE.
  • Initial studies reported sensitivities for diagnosing emboli to the segmental level (4th order branch) as high as 98%

• Supportive signs and symptoms include”

  • Sudden shortness of breath, cyanosis (turning blue) and pain felt in the chest and/or back are the main symptoms.
  • In penetrating chest wounds, the sound of air flowing through the puncture hole may indicate pneumothorax, hence the term “sucking” chest wound.
  • The flopping sound of the punctured lung is also occasionally heard.
  • Spontaneous pneumothoraces are reported in young people with a tall stature. As men are generally taller than women, there is a preponderance among males.
  • Pneumothorax can also occur as part of medical procedures, such as the insertion of a central venous catheter (an intravenous catheter) in the subclavian vein or jugular vein. While rare, it is considered a serious complication and needs immediate treatment. Other causes include mechanical ventilation, emphysema and rarely other lung diseases (pneumonia).

• Supportive signs and symptoms include:

  • The classic Meckler’s triad of symptoms includes vomiting, lower chest pain, and cervical subcutaneous emphysema following overindulgence in food or alcohol, but is observed in only half of the cases.
  • The most common chest radiograph findings in spontaneous esophageal rupture (SER) are pleural effusion (91%) and pneumothorax (80%).
  • The initial sign on a plain film may be pneumomediastinum or subcutaneous emphysema.
  • Up to 12% of patients with SER may have a normal chest radiograph.

• Next study to do:

  • Contrast-enhanced esophageal radiography is diagnostic in 75% to 85% of cases.

• Acute Coronary Syndrome
• Angina
• Aortic Aneurysm
• Aortic Stenosis
• Arryhthmias
• Bland-White-Garland Syndrome
• Cardiac tamponade
• Cor pulmonale
• Coronary Heart Disease
• Dressler’s syndrome (postpericardiotomy)
• Functional cardiac problems
• Hypertrophic Cardiomyopathy
• Mitral valve prolapse
• Myocarditis
• Pericarditis

• Abdominal distension
• Achalasia
• Carcinoma
• Cholecystitis
• Cholelithiasis
• Diverticula
• Esophageal rupture
• Esophageal spasm
• Esophagitis
• Foreign body
• Gastritis
• Gastroesophageal reflux disease (GERD)
• Hiatus Hernia
• Impacted stone
• Liver abscess
• Mallory-Weiss Syndrome
• Neoplasm
• Pancreatitis
• Peptic ulcer disease
• Perforated ulcer
• Plummer-Vinson Syndrome
• Pneumoperitoneum
• Splenic enlargement
• Splenic infarction
• Subdiaphragmatic abcsess
• Subphrenic abscess
• Whipple’s Disease

• Bechterew’s Disease
• Bone tumor
• Chest wall injuries
• Costochondritis
• CS/TS osteochondrosis
• Fractured rib
• Herpes Zoster
• Intercostal muscle spasm
• Interstitial fibrosis
• Muscle strain or spasm
• Myostitis
• Periostitis
• Soft tissue tumor
• Strain of pectoralis muscle
• Tietze’s Syndrome
• Thoracic Outlet Syndrome
• Trauma
• Vertebrogenic thoracic pain

• Asthma
• Bronchial carcinoma
• Bronchiectasis
• Bronchogenic carcinoma
• Carcinomatous effusion
• Chronic Obstructive Pulmonary Disease (COPD)
• Empyema
• Hemothorax
• Lung Abscess
• Lung Cancer
• Lymphoma
• Mediastinitis
• Mesothelioma
• Metastatic tumor
• Pleural mesothelioma
• Pleuritis
• Pleurodynia
• Pneumomediastinum
• Pneumonia
• Pneumothorax
• Pulmonary Embolism
• Pulmonary Infarction
• Retropharyngeal abscess
• Tension pneumothorax
• Thymoma
• Tracheoesophageal abscess
• Tuberculosis

• Acromegaly
• Anxiety disorders
• Collagen vascular disease with pleuritis
• Conn’s Syndrome
• Degenerative changes of cervical spine
• Depression
• Diabetes Mellitus
• Extrasystoles
• Familial Mediterranean Fever
• Hepatitis
• HIV infection
• Hyperkinetic heart syndrome
• Hyperthyroidism
• Hypoglycemia
• Hypothyroidism
• Intercostal neuralgia
• Liver Cancer
• Neurofibroma
• Neurotic
• Panic disorder
• Peritonitis
• Pheochromocytoma attack
• Pott’s Disease
• Tabes dorsalis
• Xyphodenia
• Zoster

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