Populationbased questionnaire studies show about 20% of adults reporting. Ideally, the detailed history is taken where resuscitation facilities are available. Each of these features can help focus the differential diagnosis see figure 151, table 151. The differential diagnosis of chest pain can be divided broadly into. In the uk, 1% to 2% of adults attend primary care each year with a new presentation of chest pain. A electrocardiogram ecg of a 58yearold woman presenting abdominal pain and vomiting, who, while in the emergency department developed chest pain and subsequent positive troponins. Differential dx strategies university of massachusetts. The younger the patient, the more likely an organic etiology will be found although there is rarely a serious underlying disease.
Assessment of chest pain differential diagnosis of. Mohit bhasin md, facc norfolk, va american college of. Chest pain is the presenting complaint in over 6 million emergency department visits each year. This refers to chest pain that is not sharp and is not the patients familiar angina.
Assessment of chest pain differential diagnosis of symptoms. Her findings of a fh of early ascvd, hypertension, and early surgical menopause are pertinent risk factors for development. See evaluation of the adult with chest pain in the emergency department. If this is not available locally, the patient should be referred to cardiology services. In brief, common causes of dyspnea and pleuritic chest pain are pneumonia, pe. Annually, physicians evaluate 600,000 cases of chest pain in patients aged 1021 years, a number that may reflect overwhelming concern about chest pain as a manifestation of cardiac disease as noted in older patients. Although the differential diagnosis of chest pain is exhaustive, chest pain in children is least likely to be cardiac in. It is the presenting complaint in 1% of officebased visits. Some patients presenting with chest pain will have serious acute illness with a high short.
Chest pain may be caused by either benign or lifethreatening etiologies and is usually divided into cardiac. Chest pain pediatrics clerkship the university of chicago. Prospective multicenter evaluation of cocaineassociated chest pain. This article describes the causes, assessment and differential diagnosis of musculoskeletal chest wall pain, and the management of its most common causes. In clinical practice, there is an accumulated body of evidence that outpatient ecgs should be stored or transmitted to a. Although the differential diagnosis of chest pain is exhaustive, chest pain in children is. Substernal or epigastric positional lying down may follow a meal gastroesophageal reflux disease, or gerd occurs when acidic digestive juices flow backward from the stomach into the esophagus. Esophageal disorders of the esophagus mimics chest pain from a heart attack. Evaluation of chest pain differential diagnosis of. The differential diagnosis is extensive and includes diagnoses that can be. Diagnosing the cause of chest pain american family physician. Once the clinical examination has narrowed the differential diagnosis, diagnostic testing helps determine whether the patient has a serious. There are several lifethreatening causes of chest pain which need to be evaluated for first, which include. Chest pain is a common chief complaint, accounting for approximately 5% of all emergency department visits in the us per year.
Christopher cheung approach to pediatric abdominal. Chest pain is pain or discomfort in the chest, typically the front of the chest. Chest pain is something that cannot be neglected under any circumstances whatsoever. Chest pain that radiates to the back, jaw, left arm or left shoulder. Differential diagnosis of pulmonary embolism in outpatients with nonspecific cardiopulmonary symptoms article pdf available in internal and emergency medicine 88. Acute intoxication view in chinese also present as chest pain following cocaine abuse. Chest pain is a common general practice presentation that requires careful diagnostic assessment because of its diverse and potentially serious causes. A patient with chest pain poses one of the most complicated diagnostic challenges.
It may be described as sharp, dull, pressure, heaviness or squeezing. Aug 20, 2018 chest pain is a common reason parents seek medical attention for their children. In particular, aaa might be considered in the differential diagnosis of an older patient with symptoms suggestive of renal colic. Associated symptoms may include pain in the shoulder, arm, upper abdomen or jaw or nausea, sweating or shortness of breath. The evaluation of chest pain in the emergency department is discussed elsewhere. The interdisciplinary management of acute chest pain. To understand the differential diagnosis of chest pain requiring cardiac surgical consultation. Of all patients presenting to primary care with chest pain 12% of all consultations, around 15% are thought to be nonspecific i.
Cause grouping differentials classical history classic examination findings investigation findings initial test, diagnostic test. Differential diagnosis for chest pain oxford medical education. Evaluation of chest pain differential diagnosis of symptoms. Differential diagnosis of pulmonary embolism in outpatients with nonspecific cardiopulmonary symptoms article pdf available in internal and emergency medicine 88 november 2011 with 368 reads. Combined hospital and primary care data produced an incidence of cardiac chest pain of 6. As appropriate, alternative diagnoses including the. Oshea and others published differential diagnosis of chest pain find, read and cite all the research you need on. Pulmonary embolism patients typically present with. Pdf differential diagnosis of pulmonary embolism in. Nov 15, 2005 once the clinical examination has narrowed the differential diagnosis, diagnostic testing helps determine whether the patient has a serious condition. Coronary syndrome acs or other lifethreatening emergencies suspected. Chest pain is a common pediatric complaint with the average presenting age of 12.
Feb 01, 20 outpatient diagnosis of acute chest pain in adults this is a corrected version of the article that appeared in print. Management of palpitations in urgent care automated readings in ecg machines use builtin software that does not always provide an accurate diagnosis. Chest pain with features of angina pectoris this patients description of dull, aching, exertion related substernal chest pain is suggestive of ischemic cardiac origin. This causes shortness of breath, coughing, chest pain, and wheezing, similar to asthma. The differential diagnosis of chest pain syndrome is broad and disparate, including disease processes that range from nonurgent to life threatening. The differential diagnosis is broad and includes cardiac e. Common and important causes of chest pain for doctors and medical students. If its not asthma, thats important to know, because the strategy for obtaining ideal control of your symptoms is likely to be different than the strategy for. The differential diagnosis of chest pain is broad and. When this happens in adults, it usually occurs in those with neurological disorders, parkinsons disease, strokes, the mentally challenged, airway or esophagus abnormalities, the elderly, or. The initial pivotal points are the acuity of onset of the pain and the presence of vital sign abnormalities.
Chest pain whether in the office ed or inpatient settingwhether in the office, ed, or inpatient setting, the patient with chest pain presents a diagnostic dilemma you can not treat all patients with chest pain the same due to the broad differential diagnosis that ranges from benign causes to. Mi myocardial infarction occurs when blood supply to the myocardium via coronary. Evaluation of patients with chest painwith chest pain. Syncope and vomiting may also be associated with aaa. Treatment response treatment begun with ripe sputum culture grew m. May 25, 2018 differential diagnosis for abdominal pain based on history and physical examination in spite of the fact that area of stomach pain or abdominal pain directs the underlying assessment, related signs and indications are prescient of certain reasons for pain in the abdomen and can limit the differential diagnosis. Coronary heart disease is the cause in up to 25% of cases. White massachusetts general hospital the differential diagnosis of chest pain pain in the chest may be a manifestation of many widely differing disease processes. Approach to undifferentiated chest pain in the emergency.
Distinguishing whether a patient presenting with chest pain has acs or a non acs problem is at best difficult. Differential diagnosis for abdominal pain based on history and physical examination in spite of the fact that area of stomach pain or abdominal pain directs the underlying assessment, related signs and indications are prescient of certain reasons for pain in the abdomen and can limit the differential diagnosis. For this reason, in general, additional tests are required to establish the diagnosis. Value and limitations of chest pain history in the evaluation of. It is the presenting complaint in 1% of clinicbased visits. Chest pain may be pleuritic or nonpleuritic and acute or chronicrecurrent. Specific arrhythmias may be overread or not accurately diag nosed. In other situations where immediate admission may not be indicated, a full. Chest pain is a common complaint and encompasses a broad differential diagnosis that includes several lifethreatening causes. Furthermore, within the consideration of lifethreatening causes, patients may be suffering from coronary causes, as well as pulmonary embolism. Pulmonary embolism is the most common serious cause, found in.
Nontraumatic chest pain is one of the most common causes of emergency department visits and is common in both inpatients and outpatients. Differential diagnosis of chest pain pain is a common health condition, and is usually temporary in nature. This article throws light on some possible diagnosis. Epidemiology of chest pain reflects selection bias. The quest to rule out other causes of asthmalike symptoms, or to rule in asthma as the likely cause, is called differential diagnosis.
Churchills pocketbook of differential diagnosis is the best differential diagnosis book for medical students who are working or are looking forward to more of the clinical approach to the field. Hopewell case 2 differential diagnosis of tb 2 case 2. Chest pain differential diagnosis linkedin slideshare. A patient with persistent symptoms may warrant a new evaluation. Left ventriculogram demonstrated distal anterior and apical hypokinesis.
Differential diagnosis for chest pain oxford medical. The differential diagnosis of chest pain sciencedirect. Differential diagnosis of low back pain article pdf available in seminars in pain medicine 23. A case series of 181 adults with clinically suspected the differential diagnosis includes other conditions with similar symptoms and signs, cocaine. In fact, more than 45% of pediatric chest pain cases elude definitive diagnosis. Chest pain knowledge for medical students and physicians. Evaluation of chest pain in 2019 american college of physicians. A thorough history and physical examination will help differentiate a serious cause from a. Chest pain covered extensively in chapter 9 is another pivotal clue in patients with dyspnea. Outpatient diagnosis of acute chest pain in adults american. History of exertional chest pain or exertional syncope. Patients may call chest symptoms pressure, discomfort, tightness, funny feeling, etc. Uncommon differential diagnoses and potential complications table 6 uncommon differential diagnosis for abdominal pain medical condition relevant findings and potential complications gastrointestinal intussusception colicky pain, flexing of legs, fever, lethargy, vomiting, peak incidence in children at. Differential diagnosis of chest pain request pdf researchgate.
Chest pain david ponka, md and michael kirlew, md dr ponka is an assistant professor and dr kirlew is a secondyear resident in the department of family medicine at the university of ottawa in ontario. The patient needs to be assessed at a rapid access chest pain clinic. Pleuritic chest pain is characterized by sudden and intense sharp, stabbing, or burning pain in the chest when inhaling and exhaling. Because acute chest pain, depending on its etiology, may be associated with a high risk of death, rapid, goaloriented management is mandatory. Before ordering a test elicit patients fears false negative stress testing, invasive procedures, expectations resume exercise with confidence, and define a successful chest pain workup together. The differential diagnosis is extensive and includes diagnoses that can be imminently lifethreatening. In rosens emergency medicine concepts and clinical practice 8th ed.
Chest pain that is reproducible during the physical exam with contact of the chest wall is more indicative of noncardiac chest pain, but still cannot completely rule out acute coronary syndrome. Sep 01, 2018 hollander je, hoffman rs, gennis p, et al. Identifying emergency department patients with chest pain who. An expert algorithm to assist in the diagnosis of chest pain can be found here to go back to the main page on unstable angina, click here overview. Differential diagnosis of chest pain is generated almost entirely by history, with some addition of exg, chest xray, and specific laboratory exams. Outpatient chest pain up to 16% of outpatient chest pain evaluations may never reach a definitive diagnosis. Chest pain cardiac or not treat patient as though he is critical until proved otherwise history risk factors, ho ihd, previous rxs, previous chest pain pain heart burn burning. Nov 06, 2015 acute chest pain of nontraumatic origin is a common reason for presentation to physicians offices and emergency rooms. Jun 06, 2016 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 breathin or cannot lie down. However, when we speak of chest pain, the reason behind the same need not be something temporary. Acute chest pain of nontraumatic origin is a common reason for presentation to physicians offices and emergency rooms.
Differentiating acute coronary syndrome acs from other, noncardiac causes of chest pain is imperative in emergency practice. It can be divided into heartrelated and nonheartrelated pain. If the chest pain has any of the features listed above, other causes of chest pain such as gastrointestinal disease or musculoskeletal pain should be considered. Although the differential diagnosis of chest pain is exhaustive, chest pain in children is least likely to be cardiac in origin.
403 535 269 496 1258 969 1051 1355 213 215 1361 879 1041 989 57 26 1221 721 1291 1215 1053 27 213 436 642 704 945 190 419 242 955 1070 168 848 947 1360 1461 1163 1159 513 64 1115