Differential diagnosisDifferential diagnosis in patients in patients with with chest painchest pain

Cardiac Cardiac ((MIMI, , AnginaAngina pectorispectoris, Pericarditis, AD), Pericarditis, AD)

Pulmonary causes Pulmonary causes ((PEPE, , PneumothoraxPneumothorax, pneumonia), pneumonia)

Psychosocial Psychosocial anxietyanxiety

MusculoskeletalMusculoskeletal ((costochondritis, costochondritis, strain)strain)

Gastrointestinal Gastrointestinal ((GERD,E.spasm)GERD,E.spasm)

Nonspecific chest pain Nonspecific chest pain

PROPER HISTORY

EXAMINATION

GENERAL EXAMINATIONGENERAL APPEARANCE APPEARANCE-

DISTRESSED/LEVINE SIGN

BUILT AND NOURISHMENT

PALLOR:EXACERBATE ANGINA/HEART FAILURE

ICTERUS

CYANOSIS

CLUBBING

OEDEMA- limb swelling( DVT-Pulmonary swelling( DVT-Pulmonary embolism)embolism)

LYMPHADENOPATHY

EXAMINE ALL LYMPH NODES

ARTERIAL PULSERATERHYTHMCHARACTER-pulses paradoxes(constrictive

pericarditis)VOLUMEVESSEL WALL CONDITION-thickening-

atherosclerosisOTHERPERIPHERAL PULSATIONS

BLOOD PRESSUREHypotensionHypotension can occur in can occur in √√ MIMI√√Pericardial Pericardial temponadetemponade√√PleuralEffusionPleuralEffusion√√GI bleedingGI bleeding

BP both arms not equalBP both arms not equalAORTIC AORTIC DISSECTIONDISSECTION

RESPIRATORY RATE14-16/min

JUGULAR VENOUS PULSE

ELEVATED√ RIGHT VENTRICULAR INFARCTION

√ PULMONARY EMBOLISM

√CONSTRICTIVE PERICARDITIS

TEMPERATUREPYREXIA:

FIRST 3 DAY AFTER MI

Fever suggest infectious cause

HEAD –FOOT EXAMINATIONXanthoma and

xanthelasma Arcus senilisDeformity

INSPECTION

PALPATION

PERCUSSION

AUSCULTATION

INSPECTIONSKIN-rash of shinglesSigns of trauma /swellingCVS-Any visible pulsations,JVPRESPIRATORY-Movements of chest

wall,position of trachea(*deviation away from side affected-Pneumothorax)

PALPATIONLocalised tendernessHyperesthesia-Herpes ZosterCrepitus-rib fractureCVS-Apex beat,Thrills,Palpable s3/s4 ,any

other palpable events

RESPIRATORY-position of trachea, respiratory movements(

Pneumothorax ),Vocal fremitus,Chest expansion

PERCUSSIONPneumothoraxhyper resonantPneumoniadull

AUSCULTATIONCVSS1/S2S3/S4(MI-Audible s4)Murmurs(AD)RESPIRATORYBreath sounds,vocal fremitus,pleural

rub,crackles

EXAMINATION FINDINDS

SIGNS OF SYMPATHETIC ACTIVATIONSIGNS OF SYMPATHETIC ACTIVATIONPALLORPALLORSWEATINGSWEATINGTACHYCARDIATACHYCARDIA

SIGNS OF VAGAL STIMULATIONSIGNS OF VAGAL STIMULATIONVOMITINGVOMITINGBRADYCARDIABRADYCARDIA

MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTIONSIGNSSIGNS

MIAbnormal vital signs (tachycardia, Abnormal vital signs (tachycardia,

bradycardia, tachypnea, hypotension) bradycardia, tachypnea, hypotension) Signs of hypoperfusion (egSigns of hypoperfusion (eg confusion, confusion,

ashen color) ashen color) Shortness of breath Shortness of breath Asymmetric breath sounds or pulsesAsymmetric breath sounds or pulses heart murmurs heart murmurs Pulsus paradoxus > 10 mm HgPulsus paradoxus > 10 mm Hg

ClinicalClinical::

HTNHTN BP both arms not equalBP both arms not equal distal pulses diminisheddistal pulses diminishedMurmurMurmurcardiac tamponadecardiac tamponade ParaplegiaParaplegia..

RESPIRATORY CAUSEPLEURAL EFFUSION

√dull on percussion√ bronchial breathing sound√ pleural rub√ crackle

PULMONARY EMBOLISMPULMONARY EMBOLISMPhysical ExaminationPhysical ExaminationTachycardia, tachypneaTachycardia, tachypneaIf severe, can get hypotension, syncope, and If severe, can get hypotension, syncope, and

RV failure (RV failure (↑↑JVP)JVP)

PNEUMOTHORAXPNEUMOTHORAXDecreased expansion of chestDecreased expansion of chest decreased breath sounds decreased breath sounds decreased tactile/vocal fremitus on side of decreased tactile/vocal fremitus on side of

pneumothoraxpneumothoraxHyperresonant percussion noteHyperresonant percussion noteIn tension pneumothoraxIn tension pneumothorax tracheal deviation tracheal deviation

away from the side of the pneumothoraxaway from the side of the pneumothorax

MUSCULOSKELETAL CHEST PAINMUSCULOSKELETAL CHEST PAINLOCAL TENDERNESSLOCAL TENDERNESS

ENHANCED BY ENHANCED BY EMOTION,COUGHING,SNEEZINGEMOTION,COUGHING,SNEEZING

SKINHERPES ZOSTERHERPES ZOSTER

RashRashFeverFeveritcy skinitcy skinburning sensationburning sensationstabbing painstabbing paintinglingtingling

GIT CAUSESGIT CAUSES

Relief Relief antacid. antacid.

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