IM Chest Pain

The IM Chest Pain is part of the Internal Medicine section which provides High Yield information for the USMLE, COMLEX, Medical School, Residency, and as a practicing Physician. Prepare and Learn Ahead! Educating, Preparing, and Proving high-yield content, quizzes, and medical resources. to students who are interested in the medical field.

Chest Pain

• DDX:
  • Think anatomically:
    
  • Skin: laceration, burns, herpes/shingles
    
  • SQ: Abscess or cellulitis
    
  • MSK: Strains, fracture, costochondritis
    
  • Trachea: tracheitis
    
  • Esophagus: GERD, esophagitis, perf
    
  • Lung: PNA, Pleural Effusion, Pneumonia, Pulmonary Embolism (PE), Pleurisy, Sickle Cell Disease – Pulmonary Infarct
    
  • Heart: ACS, Pericarditis, Myocardial Infarct (MI), Angina
    
  • Aorta: Dissection
  • Drugs/Medication: Cocaine induced
• Physical Exam
  • History
  • – Location, Quality, Severity, Radiation, Duration, Context (exertional, postprandial, positional, cocaine use, trauma)
  • – Associated sx (sweating, Nausea, Dyspnea, Palpitations, Sense of doom)
  • – Exacerbating and alleviating factors (esp meds)
  • – H/o similar sx, known heart or lung disease, h/o diagnostic testing
  • – Cardiac risk factors (HTN, DYSL, Smoking, FH of early MI)
  • – Pulmonary embolism risk factors ( H/o DVT, coagulopathy, malignancy, recent immobilization)
  • – VS: State (or WNL or WNL except…) +/- BP in both arms
  • – General: Patient is in no acute distress
  • – Neck Exam: JVD, Carotid Auscultation = > No JVD, No bruits
  • – Chest Exam: Palpation (Chest wall tenderness), Percussion, Auscultation => No tenderness, Tactile fremitus normal, Clear breath sounds bilaterally/Clear breath sounds bilaterally, no rhonchi, rales, or wheezing;
  • – Heart Exam: Palpation, Auscultation → PMI, heart sounds,=> Apical impulse not displaced, RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard
  • – Abd Exam: Palpation, Auscultation => Soft, non-distended, non-tender, (+) BS, no hepatosplenomegaly
  • – Extremities: Inspect, Peripheral pulses, BP in both arms pulses, edema => No cyanosis, or edema, peripheral pulses 2+ and symmetric
• Low-Risk Chest Pain Features:
  • -well localized
    
  • -sharp
    
  • -non-exertional
    
  • -no diaphoresis
    
  • -no nausea or vomiting
    
  • -reproducible palpitations
• Work-up
  • – ECG
    
  • – CPK-MB, Troponin
    
  • – Chest X-ray (CXR)
    
  • – CBC with diff
    
  • – Electrolytes
    
  • – Echo
    
  • – Barium Swallow
    
  • – Upper Endoscopy

Acute Cardiovascular Illness

• (Mycoardial infarction, pulmonary embolism, aortic dissection)
• Presentation:
  • – History: Vomiting, Chest pain, Back pain, SOB
    
• Physical Exam:
  • ↑ RR, Heart murmur, unequal pulse

Acute Coronary Syndrome

• Presentation:
  
  • – History: Heavy substernal pressure feeling, shortness of breath, Nausea, Diaphoresis, Lasts minutes to starting coupe hours ago
    
• Path:
  • sudden symptoms of insufficient blood supply to the heart indicating unstable angina or acute myocardial infarction
• Physical Exam:
  • Diaphoretic, Abnormal vital signs, No high fever

Angina

• Presentation:
  • retrosternal squeezing pain that lasts for 2 minutes and occurs with exercise. It is relieved by
    rest and is not related to food intake.
  • – Angina pectoris, chest pain d/t ischemia (lack of blood, hence O2 supply) of heart muscle
    
  • – One common form of Angina is chest pain or discomfort that occurs when your heart isn’t getting enough oxygen because of reduced blood flow to heart. It is usually a symptom of coronary heart disease.
    
• Types:
  • – Abdominal angina, postprandial abdominal pain that occurs in individuals with insufficient blood flow to meet visceral demands
    
  • – Ludwig’s angina, a serious, potentially life-threatening infection of the tissues of floor of mouth
    
  • –  Prinzmetal’s angina, a syndrome typically consisting of cardiac chest pain at rest that occurs in cycles
    
  • – Vincent’s angina, trench mouth, infection of the gums leading to inflammation, bleeding, deep ulceration and necrotic gum tissue
    
  • – Angina tonsillaris, an inflammation of the tonsils
    
  • – “Angina” (song) is also the name of a single by the Gothic metal band Tristania

• DDX:
  • – Angina
    
  • – Esophageal spasm
    
  • – Esophagitis
• Work-up:
  • – ECG
    
  • – CPK-MB, troponin
    
  • – Chest X-ray (CXR)
    
  • – CBC with diff, Electrolytes
    
  • – Exercise stress test
    
  • – Upper endoscopy/pH monitor
    
  • – Cardiac catheterization

STEMI

Myocardial infarction (MI)

• Presentation:
  • sudden onset of substernal heavy chest pain that has lasted for 30 minutes and radiates to the left arm. The pain is accompanied by dyspnea, diaphoresis, and nausea. history of hypertension, hyperlipidemia, and smoking.
  • History: Substernal chest pain, dyspnea, nausea, hx of smoking, HTN
    
• Physical Exam:
  • Diaphoresis (list any abnormal vital signs)
• DDX:
  • – Myocardial infarction (MI)*
    
  • – GERD
    
  • – Angina
    
  • – Costochondritis
    
  • – Aortic dissection
    
  • – Pericarditis
    
  • – Pulmonary embolism
    
  • – Pneumothorax
• Work-up:
  • – ECG
    
  • – Cardiac Biomarkers: Troponin, CPK-MB (no longer recommended for most pts)
    
  • – Chest X-ray (CXR)
    
  • – CBC with diff, Electrolytes
    
  • – Echocardiography
    
  • – Cardiac catheterization
• Types of Infarct:
  • Lateral Infarct:
    • Circumflex artery or Diagonal
    • Leads I, aVL, V4-6
  • Inferior Infarct:
    • Right coronary artery or L Circumflex
    • Leads II, III, & aVF
  • Septal Infarct:
    • Left Anterior Descending Artery
    • V1, V2
  • Anterior Infarct:
    • Left Anterior Descending Artery occluded
    • Leads V1, V2, V3, V4
  • Posterior Infarct:
    • R Coronary Artery, Circumflex
    • ST Depression V1-V2
• Sgarbossa Criteria:
  • In setting of LBBB, the criteria for calling AMI is >3 points:
    
  • >1mm concordant STE (OR 25, 5 points)
    
  • >1mm STD in v1, v2, v3 (OR 6, 3 points)
    
  • >5mm discordant STE (OR 4.3, 2 points)
    
  • Also look at ST (baseline to T) / S (top of S to baseline) ratio <-0.25
• HEART Score:
  • History – slight 0/ moderate 1 / high 2
    
  • ECG – normal 0 / nonspecific 1 / ST depression 2
    
  • Age – <45 0 / 45-65 1 / >65
    
  • Risk factors – none 0 / 1-2 1 / >2 2
    
  • Troponin – < limit 0 / 1-3x limit 1 / >3x limit 2
    
  • Use if suspicious for STEMI but EKG is inconclusive

Aortic Dissection (Thoracic)

• Presentation:
  • sudden onset of severe chest pain that radiates to the back. history of uncontrolled hypertension.
  • History: Ripping Chest Pain, Sudden onset, Pain may migrate to neck or back
    
  • -vomiting
• Path:
  • leakage from a traumatic aneurysm of the portion of the aorta that lies within the chest
• Physical Exam:
  • Blood pressure difference between arms, Heart murmur (if aortic insufficiency), pulse differences between sides
• Risk Factors:
  • -hx of prior
    
  • -HTN, cocaine use
    
  • -connective tissue disorders
    
  • -flow abnormalities
    
  • -family hx
• DDX:
  • – Aortic Dissection
  • – MI
  • – Pericarditis
  • – Esophageal rupture
  • – Esophageal spasm
  • – GERD
  • – Pancreatitis
  • – Fat embolism
• Work-up:
  • – ECG, CPK-MB, troponin
  • – Chest X-ray (CXR)
    • CXR Findings: -widened mediastinum, -aortic knob
  • – CBC with diff, amylase, lipase
  • – Transesophageal echocardiography (TEE),
  • – MRI/MRA—aorta
  • – Aortic angiography
  • – Upper endoscopy
• Management:
  • -Strict HR and BP control
    
  • BB: esmolol infusion, labetalol infusion
    
  • CCB: diltiazem, verapamil, nicardipine
    
  • Vasodilators: nitroprusside infusion

Costochondritis

• Presentation:
  • stabbing chest pain that worsens with deep inspiration and is relieved by aspirin.
  • had a URI one week ago.
  • Chest wall tenderness is noted.
  • – History: Sharp pain, Hurts with movement and twisting
    
• Physical Exam:
  • Point tenderness causing the pain
• DDX:
  • – Costochondritis
    
  • – Pneumonia
    
  • – MI
    
  • – Pulmonary embolism
    
  • – Pericarditis
    
  • – Muscle strain
• Work-up:
  • – ECG
    
  • – CPK-MB, troponin
    
  • – Chest X-ray (CXR)
    
  • – CBC with diff
    
  • – CT—chest with IV contrast
    
  • – Doppler U/S—legs
    
  • – D-dimer

Esophageal Rupture

• Management:
  • -NPO
    
  • -Abx
    
  • -IV PPI
    
  • -Sx consult (drain and repair)

GERD

• Presentation:
  • a retrosternal burning sensation that occurs after heavy meals and when lying down. symptoms are relieved by antacids.
  • History: Heartburn, Sour taste coming up to mouth, Pregnant, Better with Antacids
• Physical Exam:
  • No fever, No pleuritic pain, No abdominal pain
  • Severe chest pain is atypical presentation but not uncommon for GERD and may worsen with recumbency overnight.
  • Other atypical symptoms may include chronic cough, wheezing, or dysphagia
  • – Classic sx of GERD is heartburn, which may be exacerbated by meals
• DDX:
  • – GERD
    
  • – Esophagitis
    
  • – Peptic ulcer disease
    
  • – Esophageal spasm
    
  • – MI
    
  • – Angina
• Work-up:
  • – ECG
    
  • – Barium swallow
    
  • – Upper endoscopy
    
  • – Esophageal pH monitoring

Herpes Zoster

• Presentation:
  • – History: Unilateral, paresthesia of skin unilateral dermatone
    
• Physical Exam:
  • Unilateral blistering rash on a dermatome fever

Pericarditis

• Presentation:
  • retrosternal, stabbing chest pain that improves when leaning forward and worsens with deep
    inspiration. had a URI one week ago.
  • – Inflammation (-itis) of the pericardium (the fibrous sac surrounding the heart).
  • – Pericarditis is further classified according to the composition of the inflammatory exudate: serous, purulent, fibrinous, and hemorrhagic types are distinguished.
  • – Acute pericarditis is more common than chronic pericarditis, and can occur as a complication of infections, immunologic conditions, or heart attack
  • – History: Pain better sitting up and leaning foward, Pleuritic pain, Started after viral URI
• Physical Exam:
  • Cardiac rub, Fever
• DDX: 
  • – Pericarditis
    
  • – Aortic dissection
    
  • – MI
    
  • – Costochondritis
    
  • – GERD
    
  • – Esophageal rupture
• Work-up:
  • – ECG
    
  • – CPK-MB, troponin
    
  • – Chest X-ray (CXR)
    
  • – Echocardiography
    
  • – CBC with diff
    
  • – Upper endoscopy

Pericardial Effusion

• Diagnosis:
  • Water Bottle Sign

Pneumothorax

• Presentation:
  • History: Pleuritic unilateral chest pain, Sudden onset, SOB
    
• Physical Exam:
  • ↑ HR, ↑ RR, ↓ unilateral breath sounds, ↓ tactile fremitus
• Management:
  • If small (<15%) and stable:
    
    • -nothing
      
  • If primary spontaneous and large:
    
    • -small-bore catheter
      
  • If severe, secondary, or tension:
    
    • -chest tube (tube thoracostomy)
      
  • (supplemental O2 in all scenarios)

Pulmonary Embolism (PE)

• Presentation:
  • acute onset of SOB at rest and pleuritic chest pain.  also presents with tachycardia, hypotension, tachypnea, and mild fever.  recovering from hip replacement surgery.
  • – History: Pleuritic Chest pain, SOB, Unilateral swollen lower left, Hx of DVT in past, Not on warfarin
• Physical Exam:
  • Tachycardia, Tachypnea, No pain to palpation of chest wall, unilateral swollen leg
• DDX:
  • – Pulmonary Embolism (PE)*
    
  • – Pneumonia
    
  • – Costochondritis
    
  • – MI
    
  • – CHF
    
  • – Aortic Dissection
• Work-up:
  • – ECG
    
  • – Chest X-ray (CXR)
    
  • – CPK-MB, troponin
    
  • – CBC with diff, Electrolytes
• Wells Score:
  • test used to assess an individual’s risk for DVT/PE
    
  • -sx
    
  • -PE is most likely dx
    
  • -tachycardic
    
  • -immobilization or sx in past 4 weeks
    
  • -prior DVT/PE
    
  • -Hemoptysis
    
  • -active malignancy
• Management:
  • -anticoagulation (heparin or Lovenox)
    
  • Massive PE/High-risk submassive: thrombolysis, hemodynamic support

Sickle cell disease-pulmonary infarction

• Presentation:
  • African-American F presents with acute onset of severe chest pain. She has a history of sickle cell disease and multiple previous hospitalizations for pain and anemia management.
  • – In sickle cell disease, an initial trigger (often infection) exacerbated by dehydration (i.e., d/t fever, tachypnea, or ↓intake) leads to sickling of RBCs within small blood vessels of lung → precipitates a cycle of relative deoxygenation that further exacerbates the sickling tendency, leading to small vessel occlusion and, ultimately, infarction of areas of the pulmonary parenchyma.
  • – Allied to this sequence is the tendency of many patients with sickle cell disease to have a component of reactive airways disease, which further decreases oxygenation.
• DDX:
  • – Sickle cell disease—pulmonary infarction*
    
  • – Pneumonia
    
  • – Pulmonary embolism
    
  • – MI
    
  • – Pneumothorax
    
  • – Aortic dissection
• Work-up:
  • – CBC peripheral smear, reticulocyte (retic) count, LDH
    
  • – Arterial Blood Gas (ABG)
    
  • – Chest X-ray (CXR)
    
  • – CPK-MB, Troponin
    
  • – ECG
    
  • – CT—chest with IV contrast