Outpatient diagnosis of acute chest pain in adults.

The Ohio State University, Columbus, OH, USA.
American family physician (Impact Factor: 1.82). 02/2013; 87(3):177-82.
Source: PubMed

ABSTRACT Approximately 1 percent of primary care office visits are for chest pain, and 1.5 percent of these patients will have unstable angina or acute myocardial infarction. The initial goal in patients presenting with chest pain is to determine if the patient needs to be referred for further testing to rule in or out acute coronary syndrome and myocardial infarction. The physician should consider patient characteristics and risk factors to help determine initial risk. Twelve-lead electrocardiography is typically the test of choice when looking for ST segment changes, new-onset left bundle branch block, presence of Q waves, and new-onset T wave inversions. For persons in whom the suspicion for ischemia is lower, other diagnoses to consider include chest wall pain/costochondritis (localized pain reproducible by palpation), gastroesophageal reflux disease (burning retrosternal pain, acid regurgitation, and a sour or bitter taste in the mouth), and panic disorder/anxiety state. Other less common but important diagnostic considerations include pneumonia (fever, egophony, and dullness to percussion), heart failure, pulmonary embolism (consider using the Wells criteria), acute pericarditis, and acute thoracic aortic dissection (acute chest or back pain with a pulse differential in the upper extremities). Persons with a higher likelihood of acute coronary syndrome should be referred to the emergency department or hospital.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Sternoclavicular joint (SCJ) arthropathy is an uncommon cause of mechanical pain. The aim of this study is to evaluate the diagnostic value of two active clinical tests for localizing the sternoclavicular joint as the source of mechanical pain. All patients between June 2011 and October 2013 that visited the orthopedic departments of three hospitals with atraumatic pain in the area of the SC joint were evaluated. Local swelling, pain at palpation, pain during arm elevation and two newly described tests (pain during active scapular protraction and retraction) were evaluated. CT images were evaluated. The patients were then divided into two groups according to whether they had a >=50% decrease in pain following the SCJ injection. Sensitivity and specificity for local swelling, the four clinical tests and CT-scan were measured. Forty eight patients were included in this study and SC joint pain was confirmed in 44. The tests with highest sensitivity were pain on palpation, (93% sensitivity) and pain during active scapular protraction (86%). CT-scan showed a sensitivity of 84%. Local swelling showed a high specificity (100%) CONCLUSION: Pain at the SCJ during active scapular protraction is a good clinical diagnostic tool for SC arthropathy.
    BMC Musculoskeletal Disorders 12/2014; 15(1):421. · 1.90 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Chest pain requires a detailed differential diagnosis with good history-taking skills to differentiate between cardiogenic and noncardiogenic causes. Moreover, when other symptoms such as fever and elevated white blood cell count are involved, it may be necessary to consider causes that include infectious sources. A 53-year-old female with no significant past medical history returned to the hospital with recurrent complaints of chest pain that was constant, substernal, reproducible, and exacerbated with inspiration and expiration. The chest pain was thought to be noncardiogenic, as electrocardiography did not demonstrate changes, and cardiac enzymes were found to be negative for signs of ischemia. The patient's blood cultures were analyzed from a previous admission and were shown to be positive for Staphylococcus aureus. The patient was started empirically on vancomycin, which was later switched to ceftriaxone as the bacteria were more sensitive to this antibiotic. A transthoracic echocardiogram did not demonstrate any vegetation or signs of endocarditis. There was a small right pleural effusion discovered on X-ray. Therefore, computed tomography as well as magnetic resonance imaging of the chest were performed, and showed osteomyelitis of the chest. The patient was continued on intravenous ceftriaxone for a total of 6 weeks. Tests for HIV, hepatitis A, B, and C were all found to be negative. The patient had no history of childhood illness, recurrent infections, or previous trauma to the chest, and had had no recent respiratory infections, pneumonia, or any underlying lung condition. Hence, her condition was thought to be a case of primary sternal osteomyelitis without known cause.
    International Medical Case Reports Journal 01/2014; 7:133-7.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Although chest pain can be ascribed to a rheumatologic condition in every three cases, rheumatologists should not miss life-threatening disorders like myocardial ischaemia, pulmonar embolism, aortic dissection, aortic aneurysm, cardiac tamponade, severe pericarditis or myocarditis. In rare event, chest pain can herald the dissection of pulmonary artery. The diagnosis of pneumonia, pleuresia, mesothelioma and pneumothorax can be tricky. Drepanocytosis can also manifest as severe pain in the chest. Diaphragm has been proposed as the origin of pain in shrinking lung syndromes from lupus patients. Hernia through the anterior diaphragmatic foramen (Morgagni's herniation) can also induce retrosternal pain. Mediastinal tumors, mediastinal fat necrosis, and thymic disorders, from hemorragiae to infarctus, can be disclosed by chest pain, as well as the even more severe infections, pneumo-mediastins and mediastinal bleedings within mediastin (sometimes linked to the breakage of a parathyroid adenoma). Regurgitations, spasms, and functional disorders of esophagus can manifest as angina-like chest pain, as well as some esophageal ulcers and cancers. Spontaneous esophageal rupture following forced vomiting (Boerhave syndrome) leads to death in 20 to 40% of patients. Pancreas and biliary duct disorders can present as low chest pain, as well as some colitis, especially when associated with colonic interposition between the liver and the diaphragm, the so-called Chilaiditi syndrome.
    Revue du Rhumatisme Monographies 08/2014;