Differential Diagnosis of Serious Conditions that Cause Acute Chest Pain

Differential Diagnosis of Serious Conditions that Cause Acute Chest Pain - Flowchart

«Flowchart»

Start

Consider

Acute coronary syndromes (Chaps. 121 and 122)

Consider

Acute coronary syndromes (Chaps. 121 and 122)

Consider

Acute coronary syndromes (Chaps. 121 and 122)

Acute coronary syndromes

End

CK, creatine phosphokinase.

Description of pain

Oppressive, constrictive, or squeezing; may radiate to arm(s), neck, back

Background history

Less severe, similar pain on exertion; + coronary risk factors

Key physical findings

Diaphoresis, pallor; S4 common; S3 less common

Description of pain

Oppressive, constrictive, or squeezing; may radiate to arm(s), neck, back

Background history

Less severe, similar pain on exertion; + coronary risk factors

Key physical findings

Diaphoresis, pallor; S4 common; S3 less common

Oppressive

Description of pain

"Tearing" or "ripping"; may travel from anterior chest to mid-back

Background history

Hypertension or Marfan syndrome (Chap. 119, 127)

Key physical findings

Weak, asymmetric peripheral pulses; possible diastolic murmur of aortic insufficiency (Chap. 116)

Description of pain

"Tearing" or "ripping"; may travel from anterior chest to mid-back

Background history

Hypertension or Marfan syndrome (Chap. 119, 127)

Key physical findings

Weak, asymmetric peripheral pulses; possible diastolic murmur of aortic insufficiency (Chap. 116)

"Tearing"

Description of pain

Crushing, sharp, pleuritic; relieved by sitting forward

Background history

Recent upper respiratory tract infection, or other conditions which predispose to pericarditis (Chap. 118)

Key physical findings

Pericardial friction rub (usually three components, best heard by sitting pt forward)

Description of pain

Crushing, sharp, pleuritic; relieved by sitting forward

Background history

Recent upper respiratory tract infection, or other conditions which predispose to pericarditis (Chap. 118)

Key physical findings

Pericardial friction rub (usually three components, best heard by sitting pt forward)

Crushing

Description of pain

Pleuritic, sharp; possibly accompanied by cough/hemoptysis

Background history

Recent surgery or other immobilization

Key physical findings

Tachypnea; possible pleural friction rub

Description of pain

Pleuritic, sharp; possibly accompanied by cough/hemoptysis

Background history

Recent surgery or other immobilization

Key physical findings

Tachypnea; possible pleural friction rub

Pleuritic

Description of pain

Very sharp, pleuritic

Background history

Recent chest trauma, or history of chronic obstructive lung disease

Key physical findings

Tachypnea; decreased breath sounds and hyperresonance over affected lung field

Description of pain

Very sharp, pleuritic

Background history

Recent chest trauma, or history of chronic obstructive lung disease

Key physical findings

Tachypnea; decreased breath sounds and hyperresonance over affected lung field

Very sharp

Description of pain

Intense substernal and epigastric; accompanied by vomiting hematemesis

Background history

Recent recurrent vomiting/retching

Key physical findings

Subcutaneous emphysema; audible crepitus adjacent to the sternum

Description of pain

Intense substernal and epigastric; accompanied by vomiting hematemesis

Background history

Recent recurrent vomiting/retching

Key physical findings

Subcutaneous emphysema; audible crepitus adjacent to the sternum

Intense substernal and epigastric

Consider

Rupture of esophagus

Consider

Rupture of esophagus

Consider

Rupture of esophagus

Consider

Acute pericarditis (Chap. 118)

Consider

Acute pericarditis (Chap. 118)

Consider

Acute pericarditis (Chap. 118)

Acute pericarditis

Consider

Aortic dissection (Chap. 127)

Consider

Aortic dissection (Chap. 127)

Consider

Aortic dissection (Chap. 127)

Aortic dissection

Consider

Acute pneumothorax (Chap. 137)

Consider

Acute pneumothorax (Chap. 137)

Consider

Acute pneumothorax (Chap. 137)

Acute pneumothorax

Consider

Pulmonary embolism (Chap. 135)

Consider

Pulmonary embolism (Chap. 135)

Consider

Pulmonary embolism (Chap. 135)

Pulmonary embolism

Confirmatory tests

Serial ECGs
Serial cardiac markers (esp. cardiac troponin)

Confirmatory tests

Serial ECGs
Serial cardiac markers (esp. cardiac troponin)

Confirmatory tests

Serial ECGs
Serial cardiac markers (esp. cardiac troponin)

Confirmatory tests

CXR - widened mediastinal silhouette
CT or transesophageal echogram: intimal flap visualized

Confirmatory tests

CXR - widened mediastinal silhouette
CT or transesophageal echogram: intimal flap visualized

Confirmatory tests

CXR - widened mediastinal silhouette
CT or transesophageal echogram: intimal flap visualized

Confirmatory tests

ECG: diffuse ST elevation and PR segment depression
Echogram: pericardial effusion often visualized

Confirmatory tests

ECG: diffuse ST elevation and PR segment depression
Echogram: pericardial effusion often visualized

Confirmatory tests

ECG: diffuse ST elevation and PR segment depression
Echogram: pericardial effusion often visualized

Confirmatory tests

Normal D-dimer makes diagnosis unlikely
CT angiography or lung scan: !!Vdot!!/!!Qdot!! mismatch
Pulmonary angiogram: arterial luminal filling defects

Confirmatory tests

Normal D-dimer makes diagnosis unlikely
CT angiography or lung scan: !!Vdot!!/!!Qdot!! mismatch
Pulmonary angiogram: arterial luminal filling defects

Confirmatory tests

Normal D-dimer makes diagnosis unlikely
CT angiography or lung scan: !!Vdot!!/!!Qdot!! mismatch
Pulmonary angiogram: arterial luminal filling defects

Normal D-dimer makes diagnosis unlikely D
CT angiography or lung scan: !!Vdot!!/!!Qdot!! mismatch
Pulmonary angiogram: arterial luminal filling defects

Confirmatory tests

CXR: radiolucency within pleural space; poss. collapse of adjacent lung segment; if tension pneumothorax, mediastinum is shifted to opp. side

Confirmatory tests

CXR: radiolucency within pleural space; poss. collapse of adjacent lung segment; if tension pneumothorax, mediastinum is shifted to opp. side

Confirmatory tests

CXR: radiolucency within pleural space; poss. collapse of adjacent lung segment; if tension pneumothorax, mediastinum is shifted to opp. side

Confirmatory tests

CXR: pneumomediastinum
Esophageal endoscopy is diagnostic

Confirmatory tests

CXR: pneumomediastinum
Esophageal endoscopy is diagnostic

Confirmatory tests

CXR: pneumomediastinum
Esophageal endoscopy is diagnostic