| | CHEST PAIN
Doorway information about patient
The patient is a 65-year-old man who comes to the clinic with 1 day of episodic chest pain
Vital signs
. Temperature : 36.7’C (98F)
. Blood pressure : 122/80 mmHg
. Pulse : 90/min
. Respiratory : 14/min
Approach to the patient
Patients with a variety of disorders raining form being musculoskeletal pain to myocardial ischemia may report chest pain . Most causes have a distinct -profile of historical features- (eg, location , quality , aggravating / relieving factors ) but clinical characteristics car rarely specific enough for a firm diagnosis (eg, pain that is worse with meals is usually due to a gastroesophageal source but can occasionally be due to cardiac angina). In addition , some causes of chest pain are notoriously difficult to identify based on clinical characteristics alone (eg, pulmonary embolism).
Although the evaluation of chest pain in clinical settings is oriented to first rule out life-threatening disorders , the differential diagnosis in the USMLE Step 2 CS exam should formulated based only on liked , without regard to seriousness ., Also , some scenarios in Step 2 Camay incorporate images , such as ECG or chest-x-ray ; you should review common abnormalities on these tests prior to the exam.
Differential diagnosis
Differential diagnosis & features of chest pain
Coronary artery disease
1 Substernal
2 Radiation to arm , shoulder , or jaw
3 Precipitated by exertion
4 Relieved by rest or nitroglycerin
Pulmonary / pleuritic (pleurisy , pneumonia pericarditis , PE)
1 Sharp . stabbing pain
2 Worse with inspiration
3 Pericarditis : Worse when lying flat
4 PE, pneumothorax : Respiratory distress ,hypoxia
Aortic (dissection , intramural hematoma)
1 Sudden , severe “tearing” pain
2 Radiates to back
3 Elderly men
4 Hypertension &risk factors for atherosclerosis
Gastrointestinal / esophageal
1 Nonexertional , relieved by antacids
2 Upper abdominal & substernal
3 Associated with regurgitation, nausea, dysphagia
4 Nocturnal pain
Chest wall / musculoskeletal
1 Persistant &/or prolonged pain
2 Worse with movement or change in position
3 Often follows repetitive activity
the most common causes of chest pain are listed in the table , alone with clinical features that are characteristic of each other , In addition , be aware of disorders in adjacent structures 9eg, neck/thyroid, liver , gall bladder , shoulder) that may cause pain in the chest. Also , herpes zoster (shingles) is a very common and frequently overlooked cause of chest pain
HISTORY AND PHYSICAL EXAMINATION
The following sections include the most common items to address in the evaluation of chest pain.
History
History of present illness
. Have you had pain like this before? If so , what was the outcome?
. Do you still have pain or has it resolved ?
. For active chest pain
1 What were you doing when the pain begin?
2 Can you think of anything that may have caused the pain?
. For resolved or intermittent chest pain?
1 How long ago did the chest pain episodes begin?
2 How often do the episodes occur?
3 How long do the episodes last?
4 What brings on the pain (eg, walking , exercising)?
5 How far can you walk before you develop chest pain or shortness of breath?
. Point to where the pain is . Do you feel it anywhere else?
. On a scale of 1 to 10 , how severe is it?
. Describe the point (eg, sharp , burning , crushing , heavy).
. Dose anything make the pain better/worse?
. Do you have other symptoms associated with the pain (eg ,shortness of breath , palpations , nausea , sweating , lightheadedness )?
. Have you had a fever?
. Have you had a cough?
. Do you have swelling in the leg?
. Do you have leg pain while walking?
. Risk factors for pulmonary embolism; Unilateral leg pain/ swelling , immobilization , recent surgery, clotting disorders
Past medical history
. Have you been diagnosed with any other medical conditions (eg , high blood pressure , diabetes , heart problems , high cholesterol)?
Family history
. Is there anyone in your immediate family with heart disease?(Note : Cornily artery disease is very common & is usually relevant to family members only of it occurs early in life.)
Social history
. Do you smoke ? At what age did you start & how much do you smoke?
. Do you drink alcohol? How much & how often?
. Do you use recreational drugs(especially cocaine or amphetamine)?
Review of system
. Pulmonary : cough , dyspnea , wheezing , hemoptysis
. Cardiovascular ; palpations , tachycardia, pedal edema, orthopnea
. Gastrointestinal : Heartburn , hematemesis, nausea/vomiting, acid reflux
Physical examination
General
. Patient position & body habitus
Cardiac
. Carotid pulse , carotid bruits; jugular venous pressure
. Location & character of point of maximum impulse
. Heart sounds : S1,S2 , murmurs , rubs, gallops
. Abdominal aorta(bruits , enlargement)
Lungs
. Work of breath/ accessory muscle use
. Lung sounds
. Signs of consolidation (Eg, dullness, egophony)
Gastrointestinal
. Epigastric tenderness
. Liver/gall bladder tenderness (Murphy sign)
Extremities
. Peripheral pulses
. Lower extremity edema
. Shoulder examination
Closing the encounter
Patients with chest pain are frequently concerned about potentially serious causes. They may also have ha previous similar (diagnosed or undiagnosed ) episodes . Asking the patient what they think may be the cause of the pain (eg “What do you think your pain is due to , or what are you concerned may be the cause of it?”) is often helpful in evaluating chest pain , both to improve patient communication and to clarify the differential diagnosis.
In most cases , the diagnostic test will be simple and familiar to the patient (eg , chest-x-ray , ECG ), but you should explain more complex tests (eg , echocardiogram , ventilation /perfusion scan) and get the patient;s permission before proceeding . Reassure the patient that the result should be available quickly and you will explain the results as soon as possible.
Diagnostic studies
Common diagnostic studies that should be considered for patients with chest pain include:
. ECG
. Chest-x-ray
. Pulse oximetry (if not provided) or arterial blood gas analysis
. High-sensitivity D-dimer
. CT pulmonary angiogram or ventilation/ perfusion scan
. Echocardiogram
. CT scan of the chest
. Barium esophagram or upper GI endoscopy
. Liver / gall bladder ultrasound
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2018/06/05 10:47pm 
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