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| {{Infobox_Disease |
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| Name = {{PAGENAME}} |
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| {{SI}} | |
| {{WikiDoc Cardiology Network Infobox}}
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| {{CMG}}
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| '''Associate Editor-In-Chief:''' {{CZ}}
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| {{Editor Join}}
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| ==Overview==
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| '''Chest pain''' is a common clinical symptom. Several life threatening disorders should be excluded upon presentation. The first diagnostic study to be ordered within 10 minutes is the [[electrocardiogram|12 lead electrocardiogram]]. A full medical history may assist in the prompt management of the patient with chest pain.
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| '''Associated symptoms of chest pain that suggest cardiac ischemia as the underlying cause include the following:'''
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| * Describing the pain as heaviness, a pressure or a "band like" tightness
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| * Radiation of the pain to [[neck]], [[jaw]] or left arm
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| * [[Diaphoresis|Sweating]]
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| * [[Nausea]]
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| * [[Palpitations]]
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| * [[Angina pectoris|Pain with exertion]]
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| * [[Dizziness]]
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| * [[Shortness of breath]]
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| * A "sense of impending doom."
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| '''In general, clinical features that are not characteristic of myocardial ischemia include the following:'''
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| *[[Myalgia|Muscular pain]]; reproduced with or brought on by shoulder and/or forearm movements or postural changes,
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| *[[Pleura]] related pain ([[pleuritic pain]]); a sharp or knifelike pain brought on by respiratory movements as deep breathing or [[cough]]
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| *Primary or sole location of discomfort in the middle or lower abdominal region
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| *Pain that may be localized at the tip of one finger, particularly over the left ventricular apex or a costo chondral junction
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| *Pain reproduced with movement or palpation of the chest wall or arms
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| *Very brief episodes of pain that last a few seconds or less
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| *Pain that radiates into the lower extremities
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| The relief of chest pain by administration of sublingual [[nitroglycerin]] in outpatient setting is not diagnostic of [[coronary artery disease]]. For instance, esophageal pain can be relieved by administration of [[nitroglycerin]]. Likewise, the relief of chest pain by the administration of liquid or chewable [[antacids]] and anti reflux drugs does not exclude [[coronary artery disease]] as the underlying etiology of the pain.
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| ==5 Life Threatening Diseases to Exclude Immediately:==
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| * [[Aortic Dissection]]
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| * [[Esophageal Rupture]]
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| * [[Myocardial Infarction]]
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| * [[Pulmonary Embolism]]
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| * [[Tension Pneumothorax]]
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| ==Differential Diagnosis of {{PAGENAME}}==
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| {|style="width:70%; height:100px" border="1"
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| |style="height:100px"; style="width:25%" border="1" bgcolor="LightSteelBlue" | '''Cardiovascular''' | |
| |style="height:100px"; style="width:75%" border="1" bgcolor="Beige" | • [[Aortic Dissection|Acute Aortic Dissection]] • [[Acute Coronary Syndrome]] • ([[unstable angina]]) • ([[non ST elevation MI]]) • ([[ST elevation MI]]) • [[Aortic Aneurysm]] • [[Aortic Stenosis]] • [[Arryhthmias]] • [[Bland-White-Garland Syndrome]] • [[Chronic Stable Angina]] • [[Cor pulmonale]] • [[Coronary Heart Disease]] • [[Dressler's syndrome | Dressler's syndrome (postpericardiotomy)]] • [[Cardiomyopathy|Hypertrophic Cardiomyopathy]] • [[Mitral valve prolapse]] • [[STEMI|Myocardial infarction]] • [[Myocarditis]] • [[tamponade|Pericardial tamponade]] • [[Pericarditis]] • [[Takotsubos cardiomyopathy]] • [[Stress cardiomyopathy]]
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| |-bgcolor="LightSteelBlue"
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| | '''Chemical / poisoning'''
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| |bgcolor="Beige"| No underlying causes •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Dermatologic'''
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| |bgcolor="Beige"| [[Herpes zoster]]•
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Drug Side Effect'''
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| |bgcolor="Beige"| Drugs to treat [[migraine headache]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Ear Nose Throat'''
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| |bgcolor="Beige"| • [[Retropharyngeal abscess]] •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Endocrine'''
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| |bgcolor="Beige"| • [[Acromegaly]]
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| |-bgcolor="LightSteelBlue"
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| | '''Environmental'''
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| |bgcolor="Beige"| No underlying causes •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Gastroenterologic'''
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| |bgcolor="Beige"| • [[Achalasia]] • [[Abdominal distension]] • [[Barret’s esophagus]] • [[Carcinoma]] • [[Cholecystitis]] • [[Cholelithiasis]] • [[Diverticulitis]] • [[Duodenitis]] • [[Esophageal rupture]] • [[Esophageal spasm]] • [[Esophagitis]] • [[Foreign body]] • [[Gastritis]] • [[Gastroesophageal reflux]] ([[GERD]]) • [[Hiatus Hernia]] • [[Impacted stone]] • [[Liver abscess]] • [[Mallory-Weiss Syndrome]] • [[Neoplasm]] • [[nutcracker's esophagus|Nutcracker's esophagus]] • [[Pancreatitis]] • [[Peptic ulcer disease]] • [[Perforated ulcer]] • [[Plummer-Vinson Syndrome]] • [[Pneumoperitoneum]] • [[Splenomegaly|Splenic enlargement]] • [[Splenic infarction]] • Subdiaphragmatic abcsess • [[Subphrenic abscess]] • [[Whipple's Disease]] •
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| |-bgcolor="LightSteelBlue"
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| | '''Genetic'''
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| |bgcolor="Beige"| No underlying causes •
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| |-bgcolor="LightSteelBlue"
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| | '''Hematologic'''
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| |bgcolor="Beige"| No underlying causes •
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| |-bgcolor="LightSteelBlue"
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| | '''Iatrogenic'''
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| |bgcolor="Beige"| No underlying causes •
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| |-bgcolor="LightSteelBlue"
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| | '''Infectious Disease'''
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| |bgcolor="Beige"| • [[Bornholm disease]] • [[Hepatitis]] • [[HIV|HIV infection]] • [[Herpes Zoster]] •
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| |-bgcolor="LightSteelBlue"
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| | '''Musculoskeletal / Ortho'''
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| |bgcolor="Beige"| • [[Bechterew's Disease]] • [[Bone tumor]] • Chest wall injuries • Chest wall pain syndrome • [[Costochondritis]] • Chosto condral tendinitis • Chosto sternal tendinitis • [[Tietze's syndrome]] • CS/TS osteochondrosis • [[Fibromyalgia]] • [[Fractured rib]] • [[Intercostal muscle spasm]] • Interstitial fibrosis • [[Intercostal neuralgia]] • [[Muscle strain or spasm]] • Myofascial pain • [[Myostitis]] • [[Neuritis]] • [[Radiculitis]] • [[Periostitis]] • [[Precordial catch syndrome]] • [[bursitis|Shoulder bursitis]] • [[tendinitis|Shoulder tendinitis]] • [[tumor|Soft tissue sarcoma or tumor]] • Sternoclavicular arthritis • Strain of pectoralis muscle • [[Thoracic Outlet Syndrome]] • [[Trauma]] • Vertebrogenic thoracic pain
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| |-bgcolor="LightSteelBlue"
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| | '''Neurologic'''
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| |bgcolor="Beige"| • [[Tabes dorsalis]] •
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| |-bgcolor="LightSteelBlue"
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| | '''Nutritional / Metabolic'''
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| |bgcolor="Beige"| No underlying causes •
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| |-bgcolor="LightSteelBlue"
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| | '''Oncologic'''
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| |bgcolor="Beige"| • [[Liver cancer]] • [[Mesothelioma]] • [[Metastatic tumor]] • [[Neurofibroma]] • [[Pheochromocytoma]] •
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| |-bgcolor="LightSteelBlue"
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| | '''Opthalmologic'''
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| |bgcolor="Beige"| No underlying causes •
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| |-bgcolor="LightSteelBlue"
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| | '''Overdose / Toxicity'''
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| |bgcolor="Beige"| No underlying causes •
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| |-bgcolor="LightSteelBlue"
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| | '''Psychiatric'''
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| |bgcolor="Beige"| • [[Anxiety|Anxiety disorders]] • [[Affective disorders]] (e.g., [[depression]]) • [[Da costa's syndrome]] • Thought disorders (e.g., [[delusions|fixed delusions]]) • [[Hyperventilation syndrome]] • [[Hypochondria]] • [[Factitious disorders]] (e.g. [[Münchausen syndrome]] • [[Fabricated or induced illness]] • Hospital addiction syndrome • [[Panic attack]] • [[Somatoform disorder]]s • [[Somatization disorder]] •
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| |-bgcolor="LightSteelBlue"
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| | '''Pulmonary'''
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| |bgcolor="Beige"| • [[Asthma]] • [[Bronchial carcinoma]] • [[Bronchiectasis]] • [[Bronchogenic carcinoma]] • [[Carcinomatous]] • [[Pleural Effusion]] • [[Chronic Obstructive Pulmonary Disease]] ([[COPD]]) • [[Empyema]] • [[Hemothorax]] • [[Lung Abscess]] • [[Lung Cancer]] • [[Lymphoma]] • [[Mediastinitis]] • [[Pleuritis]] • [[Pleurodynia]] • [[Pneumomediastinum]] • [[Pneumonia]] • [[Pneumothorax]] • [[Pulmonary Embolism]] • [[Pulmonary Infarction]] • [[pneumothorax|Tension pneumothorax]] • [[Thymoma]] • Tracheoesophageal abscess • [[Tuberculosis]] •
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| |-bgcolor="LightSteelBlue"
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| | '''Renal / Electrolyte'''
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| |bgcolor="Beige"| No underlying causes •
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| |-
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| |-bgcolor="LightSteelBlue"
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| | '''Rheum / Immune / Allergy'''
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| |bgcolor="Beige"| No underlying causes •
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| |-bgcolor="LightSteelBlue"
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| | '''Trauma'''
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| |bgcolor="Beige"| No underlying causes •
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| |-bgcolor="LightSteelBlue"
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| | '''Miscellaneous'''
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| |bgcolor="Beige"| • Collagen vascular disease with pleuritis • [[Conn's Syndrome]] • Degenerative changes of cervical spine • [[Familial mediterranean fever]] • [[Peritonitis]] • [[Pott's Disease]] • Xyphodnia •
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| | | [[File:Siren.gif|30px|link=Chest pain resident survival guide]]|| <br> || <br> |
| | | [[Chest pain resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] |
| |} | | |} |
| | {{Chest pain}} |
| | '''For resident survival guide, click [[Chest pain resident survival guide|here]]''' |
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| == Diagnosis ==
| | '''For patient information, click [[Chest pain (patient information)|here]]''' |
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| === History and Symptoms ===
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| [[Levine's sign]] | |
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| * Thorough history including:
| | {{CMG}}; '''Associate Editor(s)-In-Chief:''' {{Sara.Zand}} {{Aisha}} {{IQ}} {{CZ}}; [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com] {{AMK}}, {{nuha}} |
| *:* Onset
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| *:* Duration
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| *:* Type of pain
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| *:* Location
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| *:* Exacerbating factors
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| *:* Alleviating factors
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| *:* Radiation
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| * Risk factors for coronary artery disease:
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| *:* [[Family history]]
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| *:* [[Smoking]]
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| *:* [[Hyperlipidemia]]
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| *:* [[Diabetes]]
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| == Physical Examination == | | {{SK}} |
| * Complete physical examination including the following:
| | ==[[Chest pain overview|Overview]]== |
| *:* [[Auscultation]] of the chest
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| *:* [[Jugular venous pulse]] ([[JVP]])
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| *:* [[Palpation]] of the chest
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| *:* [[Pulse]]
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| *:* [[Fever|Temperature]]
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| === Heart === | | ==[[Chest pain historical perspective|Historical Perspective]]== |
| * Cardiovascular examination including assessment of [[murmur]]s, [[Heart sounds|gallop]]s or [[Heart sounds|rub]]s, [[carotid bruit]] and [[heart sounds]]
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| === Extremities === | | ==[[Chest pain classification|Classification]]== |
| * Evidence of [[lower limb tenderness]] or [[pain]]
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| === Other === | | ==[[Chest pain pathophysiology|Pathophysiology]]== |
| * [[Rectal examination]] is required to assess for [[occult bleeding]]
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| == Laboratory Findings == | | ==[[Chest pain causes|Causes]]== |
| On the basis of the above, a number of tests may be ordered:
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| * [[X-ray]]s of the chest and/or abdomen ([[Computed tomography|CT scanning]] may be better but is often not available)
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| * An [[electrocardiogram]] ([[ECG]])
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| * [[Ventilation/perfusion scan|V/Q scintigraphy]] or CT Pulmonary angiogram (when a [[pulmonary embolism]] is suspected)
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| * [[Blood test]]s:
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| ** [[Complete blood count]]
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| ** [[Electrolyte]]s and [[renal function]] ([[creatinine]])
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| ** [[Liver function tests|Liver enzyme]]s
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| ** [[Creatine kinase]] (and ''CK-MB'' fraction in many hospitals)
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| ** [[Troponin]] I or T (to indicate [[myocardium|myocardial]] damage)
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| ** [[D-dimer]] (when suspicion for [[pulmonary embolism]] is present but low)
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| ==Interpretation== | | ==[[Chest pain differential diagnosis|Differentiating Chest pain from other Diseases]]== |
| In finding the cause, the history given by the patient is often the most important tool. In [[angina pectoris]], for example, blood tests and other analyses are not sensitive enough (Chun & McGee 2004). The physician's typical approach is to rule-out the most dangerous causes of chest pain first (e.g., heart attack, blood clot in the lung, aneurysm). By sequential elimination or confirmation from the most serious to the least serious causes, a diagnosis of the origin of the pain is eventually made. Often, no definite cause will be found, and the focus in these cases is on excluding severe diseases and reassuring the patient. If [[acute coronary syndrome]] (e.g.[[unstable angina]]) is suspected, many patients are admitted briefly for observation, sequential ECGs, and determination of cardiac enzyme levels over time ([[creatine kinase|CK-MB]], [[troponin]] or [[myoglobin]]). On occasion, later out-patient testing may be necessary to follow-up and make better determinations on causes and therapies.
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| === [[Electrocardiogram]] ===
| | ==[[Chest pain epidemiology and demographics|Epidemiology and Demographics]]== |
| * [[ECG]] usually required for initial evaluation
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| === [[Chest X Ray]] ===
| | ==[[Chest pain risk factors|Risk Factors]]== |
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| * A [[chest X-ray]] can be useful in the initial evaluation of the patient to ascertain if there is [[cardiomegaly]], [[pulmonary edema]] and [[aortic dissection]].
| | ==[[Chest pain screening|Screening]]== |
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| === MRI and CT === | | ==[[Chest pain natural history, complications and prognosis|Natural History, Complications, and Prognosis]]== |
| * [[CT]] scan of abdomen and chest may be helpful in ruling out [[pulmonary embolism]]
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| * To rule out [[aortic dissection]], a [[CT]] scan or [[MRI]] of the chest may be indicated
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| === Echocardiography or Ultrasound === | | ==Diagnosis== |
| * [[Echocardiogram]] usually required for patients with suspected [[coronary artery disease]]
| | [[Chest pain diagnostic study of choice|Diagnostic study of choice]] | [[Chest pain history and symptoms|History and Symptoms]] | [[Chest pain physical examination|Physical Examination]] | [[Chest pain laboratory findings|Laboratory Findings]] | [[Chest pain electrocardiogram|Electrocardiogram]] | [[Chest pain x ray|X-Ray Findings]] | [[Chest pain echocardiography and ultrasound|Echocardiography and Ultrasound]] | [[Chest pain CT scan|CT-Scan Findings]] | [[Chest pain MRI|MRI Findings]] | [[Chest pain other imaging findings|Other Imaging Findings]] | [[Chest pain other diagnostic studies|Other Diagnostic Studies]] |
| * To rule out [[aortic dissection]], [[transesophageal echocardiogram]] of the chest may be indicated
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| === Other Imaging Findings ===
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| * Ventilation and quantitative (VQ) scan may be indicated for patients requiring further evaluation
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| * For patients who are suspected to have [[coronary artery disease]] may require stress testing or [[cardiac catheterization]]
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| * Peak flow studies and pulmonary function tests may be indicated for patients requiring further evaluation
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| === Other Diagnostic Studies ===
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| * Upper gastrointestinal [[endoscopy]] if [[esophagitis]] is suspected
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| ==Treatment== | | ==Treatment== |
| * Special attention to: '''airway''', '''breathing''', and '''circulation'''
| | [[Chest pain medical therapy|Medical Therapy]] | [[Chest pain interventions|Interventions]] | [[Chest pain surgery|Surgery]] | [[Chest pain primary prevention|Primary Prevention]] | [[Chest pain secondary prevention|Secondary Prevention]] | [[Chest pain cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Chest pain future or investigational therapies|Future or Investigational Therapies]] |
| * Treat all underlying etiologies as clinically indicated
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| * Supplemental O2 should be administered to patients with suspected [[coronary artery disease]]
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| == Pharmacotherapy == | | ==Case Studies== |
| | [[Chest pain case study one|Case #1]] |
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| === Acute Pharmacotherapies === | | ==Related Chapters== |
| * For patients with [[coronary artery disease]]: | | *[[NICE guidelines for management of chest pain]] |
| *:* [[Aspirin]]
| | *[[Unstable angina]] |
| *:* [[Nitroglycerin]]
| | *[[Chronic stable angina]] |
| *:* [[Morphine]] (if necessary)
| | *[[Myocardial infarction]] |
| * For patients with [[myocardial infarction]]: | | *[[Pulmonary embolism]] |
| *:* [[Heparin]]
| | *[[Pneumonia]] |
| *:* [[Beta-blockers]]
| | *[[Costochondritis]] |
| *:* [[ACE inhibitors]]
| | *[[Cardiogenic shock]] |
| *:* [[Thrombolytic therapy]]
| | *[[The Patient History in Cardiovascular Disease]] |
| *:* [[Glycoprotein IIb/IIIa inhibitors]] | | *[[Diagnosis Wikidoc: Chest Pain no ST elevation]] |
| | | *[[Diagnosis WikiDoc:Chest Pain]] |
| == Surgery and Device Based Therapy ==
| | *[[Pleuritic chest pain]] |
| * For patients in which [[myocardial infarction]] is suspected, [[angioplasty]] may be indicated | | *[[GERD]] |
| * For patients with [[aortic dissection]]s, emergent surgery may be required. | | *[[Dysphagia]] |
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| ==References== | | ==References== |
| | | {{Reflist|2}} |
| * {{cite journal | author = Chun A, McGee S | title = Bedside diagnosis of coronary artery disease: a systematic review. | journal = Am J Med | volume = 117 | issue = 5 | pages = 334-43 | year = 2004 | id = PMID 15336583}}
| | {{WikiDoc Help Menu}} |
| * {{cite journal | author = Ringstrom E, Freedman J | title = Approach to undifferentiated chest pain in the emergency department: a review of recent medical literature and published practice guidelines. | journal = Mt Sinai J Med | volume = 73 | issue = 2 | pages = 499-505 | year = 2006 | id = PMID 16568192}} ''[http://www.mssm.edu/msjournal/73/73_2_pages_499_505.pdf Full text (PDF)]''
| | {{WikiDoc Sources}} |
| * {{cite journal | author = Butler K, Swencki S | title = Chest pain: a clinical assessment. | journal = Radiol Clin North Am | volume = 44 | issue = 2 | pages = 165-79, vii | year = 2006 | id = PMID 16500201}}
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| * {{cite journal | author = Haro L, Decker W, Boie E, Wright R | title = Initial approach to the patient who has chest pain. | journal = Cardiol Clin | volume = 24 | issue = 1 | pages = 1-17, v | year = 2006 | id = PMID 16326253}}
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| * {{cite journal | author = Fox M, Forgacs I | title = Unexplained (non-cardiac) chest pain. | journal = Clin Med | volume = 6 | issue = 5 | pages = 445-9 | year = 2006 | id = PMID 17080889}}
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| == Suggested Links and Web Resources ==
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| * [http://www.emedicinehealth.com/articles/27608-1.asp Wilderness Medicine: Chest Pain] - eMedicineHealth.com
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| * [http://anginapectorisonline.com Angina Pectoris Online] Chest pain resource for nurses and those in similar professions.
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| {{Symptoms and signs}}
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| {{Electrocardiography}}
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