Diagnosis Wikidoc: Chest Pain no ST elevation

There are 4 other Life Threatening Diseases to Exclude Immediately:

1. Aortic Dissection

 * Supportive symptoms and signs include the following:
 * Back pain in 67% of cases
 * Diminution or absence of pulses in 40% of case
 * Coma, altered mental status, Cerebrovascular accident (CVA) and vagal episodes are seen in up to 20%
 * Descending dissection can lead to splanchnic ischemia, renal insufficiency, lower extremity ischemia or pulse deficits or focal neurologic deficits due to spinal cord ischemia.
 * Chest X-Ray Abnormalities Include:
 * An increased aortic diameter is the most common CXR finding, seen in up to 84% of patients.
 * A widened mediastinum is the next most common finding, seen in 15-20%.
 * Normal in 17%.
 * Pleural effusion (hemothorax) in the absence of CHF can also be another clue to dissection.
 * Next Study to Do:
 * MRI is currently thought to be the most sensitive noninvasive method of making the diagnosis of aortic dissection. As with CT, the diagnosis is made upon visualization of a double lumen with a visible flap. Sensitivity and specificity are both thought to be 98%, and the site of entry can be visualized in 85% of cases.

2. Pulmonary Embolism

 * Supportive symptoms include:
 * Shortness of breath
 * Chest pain
 * Dyspnea
 * Anxiety
 * Pleuritic chest pain
 * Supportive laboratory studies include:
 * D-dimers are formed by the degradation of fibrin clot.
 * Almost all patients with PE have some endogenous fibrinolysis, and therefore have elevated levels of D-dimer.
 * Many other processes, such as pneumonia, congestive heart failure (CHF), myocardial infarction (MI), malignancy, and surgery, are also associated with a mild degree of fibrinolysis, and hence an elevated D-dimer is not specific for pulmonary embolism.
 * Its negative predictive value, however, is 91 – 94%


 * Next study to do:
 * Spiral CT scanning is now a standard modality to non-invasively diagnose PE.
 * Initial studies reported sensitivities for diagnosing emboli to the segmental level (4th order branch) as high as 98%

3. Tension Pneumothorax

 * Supportive signs and symptoms include"
 * Sudden shortness of breath, cyanosis (turning blue) and pain felt in the chest and/or back are the main symptoms.
 * In penetrating chest wounds, the sound of air flowing through the puncture hole may indicate pneumothorax, hence the term "sucking" chest wound.
 * The flopping sound of the punctured lung is also occasionally heard.
 * Spontaneous pneumothoraces are reported in young people with a tall stature. As men are generally taller than women, there is a preponderance among males.
 * Pneumothorax can also occur as part of medical procedures, such as the insertion of a central venous catheter (an intravenous catheter) in the subclavian vein or jugular vein. While rare, it is considered a serious complication and needs immediate treatment. Other causes include mechanical ventilation, emphysema and rarely other lung diseases (pneumonia).

4. Esophageal Rupture

 * Supportive signs and symptoms include:
 * The classic Meckler's triad of symptoms includes vomiting, lower chest pain, and cervical subcutaneous emphysema following overindulgence in food or alcohol, but is observed in only half of the cases.
 * The most common chest radiograph findings in spontaneous esophageal rupture (SER) are pleural effusion (91%) and pneumothorax (80%).
 * The initial sign on a plain film may be pneumomediastinum or subcutaneous emphysema.
 * Up to 12% of patients with SER may have a normal chest radiograph.
 * Next study to do:
 * Contrast-enhanced esophageal radiography is diagnostic in 75% to 85% of cases.

Cardiovascular

 * Acute Coronary Syndrome
 * Angina
 * Aortic Aneurysm
 * Aortic Stenosis
 * Arryhthmias
 * Bland-White-Garland Syndrome
 * Cardiac tamponade
 * Cor pulmonale
 * Coronary Heart Disease
 * Dressler's syndrome (postpericardiotomy)
 * Functional cardiac problems
 * Hypertrophic Cardiomyopathy
 * Mitral valve prolapse
 * Myocarditis
 * Pericarditis

Gastrointestinal

 * Abdominal distension
 * Achalasia
 * Carcinoma
 * Cholecystitis
 * Cholelithiasis
 * Diverticula
 * Esophageal rupture
 * Esophageal spasm
 * Esophagitis
 * Foreign body
 * Gastritis
 * Gastroesophageal reflux disease (GERD)
 * Hiatus Hernia
 * Impacted stone
 * Liver abscess
 * Mallory-Weiss Syndrome
 * Neoplasm
 * Pancreatitis
 * Peptic ulcer disease
 * Perforated ulcer
 * Plummer-Vinson Syndrome
 * Pneumoperitoneum
 * Splenic enlargement
 * Splenic infarction
 * Subdiaphragmatic abcsess
 * Subphrenic abscess
 * Whipple's Disease

Musculoskeletal

 * Bechterew's Disease
 * Bone tumor
 * Chest wall injuries
 * Costochondritis
 * CS/TS osteochondrosis
 * Fractured rib
 * Herpes Zoster
 * Intercostal muscle spasm
 * Interstitial fibrosis
 * Muscle strain or spasm
 * Myostitis
 * Periostitis
 * Soft tissue tumor
 * Strain of pectoralis muscle
 * Tietze's Syndrome
 * Thoracic Outlet Syndrome
 * Trauma
 * Vertebrogenic thoracic pain

Pulmonary

 * Asthma
 * Bronchial carcinoma
 * Bronchiectasis
 * Bronchogenic carcinoma
 * Carcinomatous effusion
 * Chronic Obstructive Pulmonary Disease (COPD)
 * Empyema
 * Hemothorax
 * Lung Abscess
 * Lung Cancer
 * Lymphoma
 * Mediastinitis
 * Mesothelioma
 * Metastatic tumor
 * Pleural mesothelioma
 * Pleuritis
 * Pleurodynia
 * Pneumomediastinum
 * Pneumonia
 * Pneumothorax
 * Pulmonary Embolism
 * Pulmonary Infarction
 * Retropharyngeal abscess
 * Tension pneumothorax
 * Thymoma
 * Tracheoesophageal abscess
 * Tuberculosis

Miscellaneous

 * Acromegaly
 * Anxiety disorders
 * Collagen vascular disease with pleuritis
 * Conn's Syndrome
 * Degenerative changes of cervical spine
 * Depression
 * Diabetes Mellitus
 * Extrasystoles
 * Familial Mediterranean Fever
 * Hepatitis
 * HIV infection
 * Hyperkinetic heart syndrome
 * Hyperthyroidism
 * Hypoglycemia
 * Hypothyroidism
 * Intercostal neuralgia
 * Liver Cancer
 * Neurofibroma
 * Neurotic
 * Panic disorder
 * Peritonitis
 * Pheochromocytoma attack
 * Pott's Disease
 * Tabes dorsalis
 * Xyphodenia
 * Zoster