CONFIRMING DIAGNOSIS Endomyocardial biopsy is rarely performed to diagnose myocarditis; the procedure is invasive and costly. A negative biopsy doesn’t exclude the diagnosis, and a repeat biopsy may be needed.
ECG typically shows diffuse ST-segment and T-wave abnormalities as in pericarditis, conduction defects (prolonged PR interval), and other supraventricular arrhythmias. Echocardiography demonstrates some degree of left ventricular dysfunction, and radionuclide scanning may identify inflammatory and necrotic changes characteristic of myocarditis.
Stool and throat cultures may identify bacteria.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Pericarditis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Because pericarditis commonly coexists with other conditions, diagnosis of acute pericarditis depends on typical clinical features and elimination of other possible causes. The pericardial friction rub, a classic symptom, is a grating sound heard as the heart moves. It can usually be auscultated best during forced expiration, while the patient leans forward or is on his hands and knees in bed. It may have up to three components, corresponding to the timing of atrial systole, ventricular systole, and the rapid-filling phase of ventricular diastole. Occasionally, this friction rub is heard only briefly or not at all. Nevertheless, its presence, together with other characteristic features, is diagnostic of acute pericarditis. In addition, if acute pericarditis has caused very large pericardial effusions, physical examination reveals increased cardiac dullness and diminished or absent apical impulse and distant heart sounds.
Chest X-ray, echocardiogram, chest magnetic resonance imaging (MRI), heart MRI, heart computed tomography scan, and radionuclide scanning can detect fluid that has accumulated in the pericardial sac. They may also show enlargement of the heart and signs of inflammation or scarring, depending on the cause of pericarditis.
In patients with chronic pericarditis, acute inflammation or effusions don’t occur — only restricted cardiac filling.
Laboratory results reflect inflammation and may identify its cause:
❑ normal or elevated white blood cell count, especially in infectious pericarditis
❑ elevated erythrocyte sedimentation rate
❑ slightly elevated cardiac enzyme levels with associated myocarditis
❑ culture of pericardial fluid obtained by open surgical drainage or cardiocentesis (sometimes identifies a causative organism in bacterial or fungal pericarditis)
❑ electrocardiography showing the following changes in acute pericarditis: elevation of ST segments in the standard limb leads and most precordial leads without significant changes in QRS morphology that occur with MI, atrial ectopic rhythms such as atrial fibrillation and, in pericardial effusion, diminished QRS voltage.
Other pertinent laboratory data include blood urea nitrogen levels to check for uremia, antistreptolysin-O titers to detect rheumatic fever, and a purified protein derivative skin test to check for tuberculosis. In pericardial effusion, echocardiography is diagnostic when it shows an echo-free space between the ventricular wall and the pericardium.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Chest pain:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the chest pain isn’t severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won’t perceive the sensation he’s feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it’s constant or intermittent. If it’s intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?
Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he’s taking, if any, and ask about recent dosage or schedule changes.
Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Also, look for jugular vein distention and peripheral edema. Observe the patient’s breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, and diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, and pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness. (See Chest pain: Causes and associated findings, pages 164 to 167.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Chest Pain, Atypical:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Characteristics of the chest pain. Important questions to ask: What is the quality of pain? Where is it located? What is its duration and intensity? What symptoms accompany the pain? Does anything trigger the chest pain or make the pain better or worse? Is there any relationship between exertion and the pain?
B. Determining the likelihood of ischemic heart disease. Four major features in the initial history and physical examination can be used to determine the likelihood of IHD. They are in order of importance:
1. Angina description (definite angina, probable angina, probably not angina, and not angina).
2. Prior myocardial infarction [by history, or electrocardiographic (EKG) findings].
3. Age (risk of IHD increases with age).
4. Number of risk factors (e.g., diabetes, smoking, hypercholesterolemia, and hypertension).
C. Features suggesting nonanginal pain. Features suggesting nonanginal pain include pleuritic pain (sharp or knifelike pain brought on by respiratory movements or cough), pain localized with one finger, pain reproduced by movement or palpation of the chest wall or arms, constant pain lasting for days, and very brief episodes of pain lasting a few seconds (1).
D. Other key considerations. Key considerations in the history include the following:
1. All presentations of chest pain should be taken seriously until proven to be benign.
2. The description of pain can be greatly influenced by socioeconomic status, education, culture, and personality.
3. A review of cardiac risk factors is appropriate for all patients who present with chest pain.
4. Red flags suggesting a noncardiac, life-threatening condition include tachypnea, dyspnea, and hypoxemia.
5. Sharp, stabbing, or pleuritic qualities do not completely exclude an ischemic cause (Chapter 8.5). In the Multicenter Chest Pain Study, IHD was diagnosed in 22% of patients coming to the emergency room with a sharp quality pain (2).
Physical examination
No reliable physical signs can be used to determine whether a patient with atypical chest pain has ischemic heart disease. The main purpose of the examination is to assess the patient for evidence of complications from atherosclerotic disease (e.g., peripheral vascular disease, cerebrovascular disease, and congestive heart failure). Pay attention to findings on the vascular examination (e.g., peripheral artery bruits, retinal arteriolar changes, the presence of a cardiac gallop) and for signs of the consequences of diminished myocardial contractility (e.g., lower extremity edema or pulmonary crackles) (Chapter 7.5).
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Chest Pain, Substernal:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Characteristics of pain in stable angina
1. Quality. The pain of angina pectoris is often not described as a pain at all. Instead, it is frequently referred to as a squeezing, heaviness, or pressure sensation lasting 5 to 10 minutes. Diaphoresis, dyspnea, nausea, and vomiting often accompany the discomfort. Pain that is sharp, stabbing (especially if exacerbated by deep inspiration), pain reproducible with chest wall palpation, and pain lasting seconds or days to weeks is less likely to be from CAD.
2. Location. Generally, angina is poorly localized in the retrosternal area, anterior chest, or epigastrium and typically radiates to the left arm, neck, or jaw.
3. Precipitating and alleviating factors. Angina is often precipitated by conditions that increase myocardial oxygen demand, most commonly physical exertion, emotional stress, or cold weather. It is relieved promptly with rest or sublingual nitroglycerin.
B. Characteristics of pain in unstable angina. According to the clinical practice guidelines recently developed by the Agency for Health Care Policy (1), unstable angina is defined as:
1. Angina at rest lasting greater than 20 minutes.
2. New onset angina (< 2 months) precipitated by walking one to two blocks or by climbing one flight of stairs at a normal pace.
3. Angina that is more frequent, longer in duration, or occurring at a lower threshold.
C. Risk factors. The Framingham Heart Study along with numerous other large epidemiologic studies has established the following risk factors for CAD (2):
1. Sex and age: men aged 45 years or older; women aged 55 years or older; women with premature menopause without hormone replacement.
2. Family history: MI or sudden death occurring in a first-degree male relative aged 55 years or younger or in a first-degree female relative aged 65 years or younger.
3. Smoking: in men who smoke one pack per day, a three- to fivefold risk for CAD compared with nonsmokers. Those who quit smoking can reach the same risk level of nonsmokers within 2 years of stopping.
4. Hypertension: blood pressure greater or equal to 140/90 (Chapter 7.8).
5. Cholesterol: total cholesterol greater than 200; low-density lipoprotein (LDL) greater than 130; high-density lipoprotein (HDL) less than 35. An HDL level above 60 is protective.
6. Diabetes mellitus: a twofold increase in CAD, compared with nondiabetics (Chapter 14.1).
Physical examination
A. Focused physical examination. This should include vital signs (notably blood pressure). During a symptomatic episode, the finding of a mitral regurgitation murmur, S3 or S4 gallop, bruits or precordial lift all suggest a high likelihood of CAD. Findings of xanthelasma, tendinous xanthomata, tobacco-stained teeth and fingernails, and decreased or asymmetrical peripheral pulses indicate the likely presence of cardiac risk factors.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Acute Nonpleuritic Chest Pain:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Chest wall pain
❑ Angina
❑ Unstable angina
❑ Myocardial infarction
❑ Gastroesophageal reflux
❑ Herpes zoster
❑ Thoracic root compression
❑ Panic disorder
❑ Aortic stenosis
❑ Aortic dissection
❑ Mediastinal mass
❑ Biliary disease
Diagnostic Approach
It is essential to maintain a high index of suspicion (low threshold for investigation) for critical problems; however, most chest pain has a benign cause. The patient with myocardial ischemia often is reluctant to label the symptom as “pain.” Instead descriptors are used such as squeezing, pressure, tightness, fullness, a heavy weight on the chest, burning (attributed to indigestion),
or a toothache (when jaw radiation is present). A closed fist held to the sternum is commonly employed to explain the symptoms. Pleuritic chest pain, intensified by a deep breath, usually has a pulmonary or chest wall origin. Recurrent episodic pain or persistent pain lasting days is unlikely to represent a critical problem. Pain lasting a few seconds or pain that is sharp or stabbing in quality is almost never ischemic, especially if reproducible by palpation
or movement.
Syncope with chest pain should raise suspicion of aortic dissection,
ruptured aortic aneurysm, pulmonary embolism, or critical aortic stenosis. “Angor anomie,” a sense of impending doom, is found in serious conditions such as myocardial infarction, pulmonary embolism, aortic dissection, and to a lesser extent, panic disorder. Sternal pain may be caused by xiphoidalgia, myelomatosis, ankylosing spondylitis, osteomyelitis, or traumatic fracture.
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Source: Field Guide to Bedside Diagnosis, 2007
Pleuritic Chest Pain:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Costochondritis
❑ Pneumonia
❑ Rib fracture
❑ Pulmonary embolism
❑ Pleurisy
❑ Pneumothorax
❑ Pericarditis
❑ Lung cancer
❑ Pneumomediastinum
❑ Splenic infarction
Diagnostic Approach
Pleuritic chest pain, intensified by a deep breath, usually has a pulmonary or chest wall origin. Cardiac pain is almost never pleuritic (LR 0.2), sharp or stabbing (LR 0.3), positional (LR 0.3) or reproduced by palpation (LR 0.3).
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Source: Field Guide to Bedside Diagnosis, 2007
Endocarditis:
Diagnosis
(Handbook of Diseases)
Three or more blood cultures in a 24- to 48-hour period identify the causative organism in up to 90% of patients. The remaining 10% may have negative blood cultures, possibly suggesting fungal infection or infections that are difficult to diagnose such as Haemophilus parainfluenzae. Other abnormal but nonspecific laboratory test results include:
❑ normal or elevated white blood cell count
❑ abnormal histiocytes (macrophages)
❑ elevated erythrocyte sedimentation rate
❑ normocytic, normochromic anemia (in 70% to 90% of endocarditis cases)
❑ positive serum rheumatoid factor (in about one-half of all patients with endocarditis after the disease is present for 3 to 6 weeks).
Echocardiography may identify valvular damage. Transesophageal echocardiography allows visualization of cardiac structures. Electrocardiography may show atrial fibrillation and other arrhythmias that accompany valvular disease.
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Source: Handbook of Diseases, 2003
Myocarditis:
Diagnosis
(Handbook of Diseases)
The patient history commonly reveals recent febrile upper respiratory tract infection, viral pharyngitis, or tonsillitis. A physical examination shows supraventricular and ventricular arrhythmias, third and fourth heart sounds, a faint first heart sound, possibly a murmur of mitral insufficiency (from papillary muscle dysfunction) and, if pericarditis is present, a pericardial friction rub.
ECG typically shows diffuse STsegment and T-wave abnormalities (as in pericarditis), conduction defects (prolonged PR interval), and other supraventricular arrhythmias.
Echocardiography may show a weak heart muscle, an enlarged heart, or fluid surrounding the heart.
Stool and throat cultures may identify the causative bacteria. An endomyocardial biopsy can confirm the diagnosis, but it’s rarely performed.
Laboratory tests can’t unequivocally confirm myocarditis, but the following findings support this diagnosis:
❑ Cardiac enzyme levels (creatine kinase [CK], the CK-MB isoenzyme, aspartate aminotransferase, and lactate dehydrogenase) are elevated.
❑ White blood cell count and erythrocyte sedimentation rate are increased.
❑ Antibody titers (such as antistreptolysin O titer in rheumatic fever) are
elevated.
❑ Blood cultures may indicate infection.
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Source: Handbook of Diseases, 2003
Pericarditis:
Diagnosis
(Handbook of Diseases)
Because pericarditis often coexists with other conditions, diagnosis of acute pericarditis depends on typical clinical features and elimination of other possible causes. It may be detected with X-ray, echocardiogram, magnetic resonance imaging, computed tomography, and coronary angiography. These tests may show scarring, contracture of the pericardium, or enlargement of the heart.
CLINICAL TIP: A classic symptom, the pericardial friction rub, is a grating sound heard as the heart moves. It can usually be auscultated best during forced expiration, with the patient leaning forward or resting on his hands and knees in the bed.
Pericardial friction rub may have up to three components, corresponding to the timing of atrial systole, ventricular systole, and the rapid-filling phase of ventricular diastole, Occasionally, it’s heard only briefly or not at all. Nevertheless, its presence, together with other characteristic features, is diagnostic of acute pericarditis.
In addition, if acute pericarditis has caused large pericardial effusions, the physical examination reveals increased cardiac dullness and diminished or absent apical impulse and distant heart sounds. Acute inflammation or effusions don’t occur in patients with chronic pericarditis — only those with restricted cardiac filling.
Laboratory results reflect inflammation and may identify its cause:
❑ normal or elevated white blood cell count, especially in infectious pericarditis
❑ slightly elevated cardiac enzyme levels with associated myocarditis
❑ culture of pericardial fluid obtained by open surgical drainage or cardiocentesis (sometimes identifies a causative organism in bacterial or fungal pericarditis).
Electrocardiography shows the following changes in acute pericarditis: elevation of ST segments in the standard limb leads and most precordial leads without the significant changes in QRS-complex morphology that occur with an MI, atrial ectopic rhythms such as atrial fibrillation, and diminished QRS complex in pericardial effusion.
Other pertinent laboratory studies include blood urea nitrogen level to check for uremia, antistreptolysin O titers to detect rheumatic fever, and a purified protein derivative skin test to check for tuberculosis. In pericardial effusion, echocardiography is diagnostic when it shows an echo-free space between the ventricular wall and the pericardium.
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Source: Handbook of Diseases, 2003
Chronic fatigue and immune dysfunction syndrome:
Diagnosis
(Handbook of Diseases)
The cause and nature of CFIDS are still unknown, and no single test unequivocally confirms its presence. Therefore, the diagnosis is based on the patient’s history and the CDC criteria. Because the CDC criteria are admittedly a working concept that may not include all forms of this disease and are based on symptoms that can result from other diseases, diagnosis is difficult and uncertain. Considerable overlap exists between CFIDS and fibromyalgia syndrome, with many patients having features of both.
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Source: Handbook of Diseases, 2003
Chest pain:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Ask the patient to rate the pain using a standardized pain rating scale. Is the pain a dull, aching, pressurelike sensation, or sharp, stabbing, and knifelike? Is it constant or intermittent? If it’s intermittent, ask how long an episode lasts. Ask him about precipitating, aggravating, or alleviating factors. Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Ask about medications he’s taking, if any, including recent dosage or schedule changes.
ALERT: Chest pain in perimenopausal women may be difficult to diagnose because it may present atypically. Fatigue, nausea, dyspnea, and shoulder or neck pain are symptoms more likely to signal an MI in women than in men.
Physical examination
Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Check for jugular vein distention and peripheral edema. Observe the patient’s breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Chest pain:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the chest pain isn’t severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won’t perceive the sensation he’s feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it’s constant or intermittent. If it’s intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?
Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he’s taking, if any, and ask about recent dosage or schedule changes.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Chest Pain:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Musculoskeletal Disorders
Muscle
Trauma
Normal activitycan strain chest wall musculature.Participation in athletics or overexertionalso may injure specific muscle groups of chest wall.Blunt trauma from accidents, athleticinjuries, or physical abuse can cause chest wall contusions. Stitch
Definedas sharp pain occurring in upper quadrants of abdomen under costalmargin during strenuous activity.Resolves when exercise is over.Stress on peritoneal ligaments is thoughtto be the cause. Precordial Catch
Also calledTexidor twinge and defined as benign self-limited disorder of unknown cause.Characterized by acute onset of sharppain, usually localized over cardiac apex and occurring at restor with mild activity.Usually lasts up to 1 min but may befollowed by dull ache.Deep inspiration may aggravate pain. Sickle Cell Pain Episodes
Chest pain can occur during vasoocclusiveepisode and usually involves muscle ache. Bone/Cartilage
Trauma
Accidentalor nonaccidental trauma may produce rib fractures.Localized bone tenderness suggestsrib contusion or fracture.Chest radiography should be performed. Costochondritis
Common causeof chest pain in adolescence.Localized pain and tenderness occurover the affected costochondral junction. Left fourth and fifthjunctions are most commonly involved. Sickle Cell Disease (Thoracic Bone Infarction)
Chest painmay occur as result of thoracic bone infarction that may affectribs, sternum, or vertebrae.Nuclear scintigraphy can demonstrateinfarction. Slipping-Rib Syndrome
Pain isthought to arise from eighth, ninth, or tenth ribs overriding theone above.Diagnosis may be confirmed by graspingcostal margin and pulling anteriorly to reproduce pain (hookingmaneuver). Same maneuver may produce palpable click as cartilagesslip over one another. Tietze Syndrome
Syndromeof unknown cause characterized by swelling at right sternoclavicularor second sternochondral junction.Pain may last for weeks with frequentremissions and exacerbations. Osteomyelitis
Localizedpain and tenderness along with fever characterize osteomyelitisof sternum or rib.S. aureus is most common pathogen.Nonspecific lab findings are leukocytosisand increased erythrocyte sedimentation rate.Although chest radiograph may be normalearly in illness, nuclear scintigraphy reveals localized uptakeof radionuclide.In 10–14 days, chest radiographyshows periosteal bone formation and destructive lesions.Bone aspiration or biopsy is usuallydiagnostic. Neoplasm
Bone tumorsof chest wall are rare; however, neoplastic disease may cause localized ribor sternal pain.Acute lymphoblastic leukemia may involvesternum or ribs. Chest pain is not infrequent during course of thisillness but is rarely presenting symptom. Metastatic neuroblastomaalso may cause bone pain.See Chap.1, Abdominal Masses and Chap. 38, Lymphadenopathy. Trachea and Proximal Bronchi Disorders
Tracheobronchialpain usually occurs in neck or chest where inflammation is.See Chap.10, Cough. Parietal Pleura Disorders
Intercostal nerves conduct pain impulsesfrom parietal pleura to spinal cord. Pneumonia
Most commoncause of pleuritic chest pain is pneumonia.Pain is localized, sharp, stabbing,and knifelike and usually occurs with inspiration. Shallow breathsminimize pain, whereas laughing and coughing aggravate it. Pleuralfriction rub indicates pleural involvement.Chest radiograph shows infiltrate andsometimes pleural effusion.See Chap.10, Cough). Pleurodynia
Self-limitedillness usually caused by enteroviral infection.Fever and paroxysms of sharp chestpain without evidence of pneumonia are usual presenting clinicalfeatures. Pain usually subsides within 1 wk.Positive pharyngeal viral culture or4-fold increase in antibody titer is diagnostic. Empyema
Definedas presence of pus in pleural space and usually occurs from extensionof bacterial pneumonia.Most common pathogen in pediatric populationis S. pneumoniae.High spiking fever, respiratory distress,and occasional chest pain characterize empyema. Usually no breathsounds are heard over affected area.Chest radiograph shows effusion, butthoracentesis must be performed for specific diagnosis. Analysisof fluid should include white cell and differential counts; Gramand acid-fast stains; protein; glucose; and aerobic, anaerobic,fungal, and acid-fast cultures. Pneumothorax
Definedas accumulation of air in pleural space.Common causes include penetrating woundsof chest, rib fracture, positive pressure ventilation, pneumonia,cystic fibrosis, and idiopathic.Although chest pain is acute, unilateral,and severe, degree of respiratory distress depends on how largepneumothorax is. Large pneumothorax results in hyperresonance topercussion on involved side.Chest radiography is diagnostic. Hemothorax
Definedas collection of blood in pleural space.Most common cause is trauma, surgicalor nonsurgical.Degree of respiratory distress dependson size of hemothorax. Decreased breath sounds and dullness to percussionover affected side of chest usually occur.Chest radiograph that shows collapseof lung surrounded by opacification suggests presence of hemothorax.Diagnosis is confirmed by thoracentesis. Pneumomediastinum
Definedas presence of air or gas in mediastinum that can cause acute, severechest pain that may be referred to back, shoulders, and neck.Palpation of subcutaneous air in softtissues of chest wall or neck signifies presence of mediastinalemphysema.Common causes include pneumothoraxwith dissection of air into mediastinum, asthma, cystic fibrosis,and chest trauma with disruption of tracheobronchial tree.Chest radiography is diagnostic. Postpericardiotomy Syndrome
Thoughtto be immunologic reaction associated with introduction or reactivationof virus at time of intrapericardial surgery.Usually occurs 1–3 wks aftersurgery in children >2 yrs.Clinical manifestations include fever,chest pain, pericardial and pleural effusions, and sometimes pulmonaryparenchymal disease. Sharp or dull pain is precordial in locationand worsens with inspiration and lying down. Pleural and pericardialfriction rubs may be heard, unless there are significant effusions.Pericardial effusions can be life threateningif they are large.Serum may be positive for antiheartantibody.Average duration of illness is 2–3wks, but recurrences sometimes occur months or years later. Pulmonary Embolism
Definedas thrombus or any foreign material (e.g., air or fat) in pulmonaryarteries that causes obstruction of pulmonary blood flow.Risk factors in pediatric populationinclude deep venous thrombosis, central venous catheter, prolongedimmobilization, ventriculoatrial shunt, right-sided endocarditis,intravenous drug use, septicemia, and severe dehydration.Chest pain associated with pulmonaryembolism is acute and can be pleuritic or nonpleuritic. Usuallyassociated with dyspnea. Other findings include sweating, nausea,vomiting, palpitations, syncope, and anxiety.Physical exam commonly reveals tachycardia,dyspnea or tachypnea, and fever. Other findings include crackles,wheezes, pleural friction rub, prominent RV impulse, accentuatedpulmonary closure sound, S4 gallop, systolic ejection murmur alongsternal border, hepatomegaly, and edema.Chest radiograph is normal or showsconsolidation, atelectasis, or pleural effusion.ECG findings include ST-segment orT-wave changes in right precordial leads and RV hypertrophy.Pulmonary isotope lung perfusion scanthat shows bilateral segmental defects strongly suggests presenceof pulmonary emboli, whereas normal scan effectively excludes pulmonaryemboli. If scan is abnormal, ventilation (xenon) scan should beperformed. With pulmonary emboli, perfusion scan should be abnormaland ventilation scan normal.MRI also may be useful in diagnosisof pulmonary embolism. If diagnosis is still uncertain, pulmonaryangiogram is best way to establish presence of pulmonary embolism. Neoplasm
Primarychest neoplasms are rare in children.Chest pain is usually secondary topleural metastases, which can occur with Wilms tumor, osteogenicsarcoma, neuroblastoma, or rhabdomyosarcoma.Chest radiography may show mass ormetastases.Chest CT locates and defines extentof mass or metastases.Histologic diagnosis is definitive. Cardiac Disorders
Cardiacdisorders that cause chest pain usually produce myocardial ischemiaor inflammation of parietal pericardium.Middle and inferior cardiac nervesconduct myocardial pain impulses to upper thoracic rami, sympatheticchain, and spinal cord. Pain impulses from upper parietal pericardiumtravel along intercostal nerves, and those from lower pericardiumtravel along phrenic nerves and then to spinal cord. Myocardial Ischemia Including Infarction
Myocardialischemia causes angina, which has been described as gripping, crushing, sharp,knifelike pain in retrosternal or left chest areas that usuallyfollows exercise or exertion and is relieved by rest. Pain may betransmitted to neck, shoulder, arm, or back. In some cases, myocardialinfarction may occur. Tachypnea, tachycardia, gallop rhythm, sweating,nausea, and vomiting are common findings.Causes of myocardial ischemia includesevere aortic stenosis, coronary artery anomalies (including anomalouscoronary artery from pulmonary artery), myocarditis, cardiomyopathy,Kawasaki disease, familial dysproteinemias, and cocaine use.ECG changes may indicate myocardialischemia or injury. ECG leads overlying subepicardial or transmuralischemic area show inverted T waves. Symmetric tall peaked T wavesare seen in leads overlying subendocardial ischemic area. Leadsoverlying subendocardial injury show ST depression with concaveor flat contour, whereas those overlying subepicardial injury showST elevation with upwardly convex or concave contour. Within hoursto days of myocardial infarction, Q waves and inverted T waves appearin leads overlying infarction.2-D echocardiogram may show local orgeneralized myocardial dysfunction.Elevation of creatine kinase MB fractionor troponin T is usually found with destruction of myocardial tissue.Nuclear scintigraphy of myocardiummay show decreased local uptake.Cardiac catheterization and angiographyare necessary in some cases for definitive diagnosis. Pericarditis
Most commoncauses in children are viral infection, acute rheumatic fever, andpostpericardiotomy syndrome. Less common are purulent pericarditis,uremia, systemic lupus erythematosus, juvenile rheumatoid arthritis,and radiation therapy.Triad of fever, chest pain, and pericardialfriction rub signify pericarditis.Chest pain is usually acute and substernalwith radiation to neck, shoulders, and arms. Sitting up and leaningforward eases pain, whereas deep breathing, coughing, and lyingdown aggravate it.ECG shows elevated ST segments in nearlyall leads that progress to T-wave flattening and inversion in someof the leads, which may persist for months after acute lesion hasresolved.2-D echocardiography commonly revealspericardial effusion. Mitral Valve Prolapse
Associationof chest pain and mitral valve prolapse has been seriously questioned, bothin adults and children. Mechanism of pain, which is ill definedand usually nonexertional, is uncertain. Other causes of chest painshould be considered in children with chest pain and mitral valveprolapse.Midsystolic click or late systolicmurmur (mitral incompetence) or both are heard at apex.M-mode or 2-D echocardiography confirmsdiagnosis of mitral valve prolapse. Arrhythmias
Supraventriculartachycardia may cause some chest discomfort as well as cardiac failure.Sinus tachycardia or premature ventricularcontractions have been associated with palpitations.Important to differentiate by historywhether child is having chest pain or different sensation causedby palpitations.ECG rhythm strip confirms diagnosisof arrhythmia. If cardiac rhythm is normal, Holter monitoring maybe useful.With intermittent chest pain and suspectedarrhythmia, event recorder is another useful diagnostic technique. Diaphragm Disorders
Intercostalnerves conduct impulses from peripheral diaphragm to spinal cord. Phrenicnerves (C3–C5) conduct pain impulses from central diaphragmto spinal cord.With diaphragmatic irritation, painmay radiate to lower chest or shoulder, depending on extent of involvement.Possible causes include subphrenicor hepatic abscess and perihepatitis (Fitz-Hugh-Curtis syndrome). Gastrointestinal Disorders
Esophagus
Gastroesophageal Reflux
Common causeof transient chest pain is reflux of gastric contents from stomachinto esophagus. Severe reflux may lead to esophagitis with persistentchest pain.Monitoring for 24 hrs with esophagealpH probe can determine presence and severity of reflux. Endoscopywith biopsy can diagnose esophagitis.See Chap.55, Regurgitation and Vomiting). Caustic Ingestion
Ingestionof caustic substances may cause sharp or burning pain in midsternaland lower chest.Esophagoscopy is diagnostic. Foreign Body
Foreignbody lodged in esophagus commonly causes choking, drooling, anddifficulty swallowing. Associated dull ache also may occur.Chronically impacted foreign body maycause esophagitis.If foreign body is radiopaque, maybe seen on chest radiograph. Otherwise, filling defect may be seenon esophagram.Esophagoscopy is diagnostic for chronicallyimpacted foreign body. Hiatal Hernia
Definedas sliding hernia with gastroesophageal junction lying above diaphragm.Symptoms of hiatal hernia are thoseof gastroesophageal reflux with epigastric and lower chest paincommonly occurring after meals.Sometimes large hiatal hernia may beseen on plain radiograph with retrocardiac mass extending to rightlateral chest wall.Upper GI series is diagnostic. Spasm
May causechoking episodes during feeding, difficulty in swallowing, and substernal chestache.May be related to stress, rapid eating,and drinking cold liquids.Upper GI series with video playbackcapability is diagnostic. Tear
Persistentsevere vomiting may produce acute esophageal tear, which causeschest pain along with hematemesis.Esophagoscopy is diagnostic. Referred Pain
Gastritis,peptic ulcer disease, cholecystitis, and pancreatitis may causereferred chest pain.See Chap.2, Abdominal Pain. Neurologic Disorders
Intercostal Nerve
Trauma
Injury to intercostal nerve may produce painin dermatome supplied by nerve. Herpes Zoster Neuritis
Herpes zostercan cause painful, vesicular lesions along ≥1 dermatomes correspondingto intercostal nerves.Positive viral culture of lesion isconfirmatory. Dorsal Root
Trauma (fractures)or spinal disease (tumor, osteomyelitis, epidural abscess) can involvecervical or upper thoracic dorsal roots and cause chest pain.Pain often occurs with body motionor after coughing, sneezing, or laughing. Hypesthesia to pin prickor light touch may be found in affected dermatomes.Useful diagnostic tests include cervicaland thoracic spine radiographs, nuclear scintigraphy, CT, and MRI. Psychologic Disorders
Anxietywith or without hyperventilation, depression, school phobia, hypochondriasis,and conversion reactions are common causes of chest pain, especiallyin adolescence.Pain has no particular characteristicsand usually diminishes once patients can talk about problem andreceive reassurance that they are not seriously ill.Hyperventilation attacks are most commonin girls and may produce air hunger, dizziness, syncope, palpitations,and paresthesias.Generally, specific stressful situationthat is related to onset of chest pain can be identified.Family history of chest pain and occurrenceof recurrent somatic complaints (e.g., headache and abdominal pain)are also common.To make diagnosis of psychogenic chestpain, positive clinical psychologic evidence must exist.Onset of pain in association with stressfulemotional situation suggests that pain is manifestation of psychologicproblem.In general, psychologic symptoms donot occur in isolation but are accompanied by other signs of unhappinessand anxiety.Psychosocial history is most usefulclinical tool in making diagnosis of psychogenic chest pain. Idiopathic Chest Pain
Most commoncause of chest pain in childhood and adolescence is idiopathic.Such pain is nonspecific but may be recurrent or chronic.This is diagnosis of exclusion. Diagnostic Approach
Most commoncauses of chest pain in pediatric population are idiopathic, musculoskeletal,and psychologic.If complaint has been present for >6mos, organic cause is less likely.History and physical exam are diagnosticin many cases.Chest radiography should be performedwith localized rib or bone pain, any respiratory distress, or suspectedpulmonary disorder.With suspected heart disease, ECG shouldbe performed.2-D echocardiography may be necessary,depending on suspected diagnosis.Psychologic causes must be substantiatedby clinical psychologic evidence.Children in whom no definite causecan be found are more likely to complain recurrently, presumablyfor secondary gain.In adolescence, chest pain is frequentcomplaint, but it is usually benign. Knowledge about recent lifeevents and individual's beliefs about the symptom are importantin managing this problem.
» READ BOOK EXCERPT ONLINE »
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Chest pain:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the chest pain isn't severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Ask when the pain began and if the patient ever experienced this type of pain in the past. Sometimes a patient won't perceive the sensation he's feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Ask him to rate the pain on a pain scale. Find out whether it's constant or intermittent. If it's intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?
Review the patient's history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he's taking, if any, and ask about recent dosage or schedule changes.
Take the patient's vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Place the patient on a cardiac monitor and evaluate his heart rhythm. Also, look for jugular vein distention and peripheral edema. Note the feel of his skin. Is it cool and clammy or warm and diaphoretic? Auscultate his chest for extra heart sounds. Observe the patient's breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
CHEST PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A possible myocardial infarction must be the first consideration in all
adults with acute chest pain, especially if there are significant
alterations of the vital signs. Consequently, serial ECGs, serial cardiac
enzymes, and
hospitalization will often be necessary. After this condition has been excluded, we can turn our
attention to the other possibilities. Arterial blood gases, chest x-ray, and
a lung scan may be ordered to exclude a pulmonary embolism. Pulmonary
angiography may be necessary in some cases. A chest x-ray may be ordered to
rule out pneumonia. Acute chest pain related to esophagitis is often
relieved by swallowing lidocaine viscus, an extremely useful tool in the
differential diagnosis. Relief of the pain with nitroglycerin under the
tongue or by spray will support the diagnosis of coronary insufficiency.
Tenderness of the costochondral junctions with relief on lidocaine injection
into the point of maximum tenderness suggests Tietze syndrome
(costochondritis). In cases of chronic chest pain, an exercise tolerance
test with thallium scan should be done to rule out coronary insufficiency or
myocardial infarction. It may be wise to do immediate coronary angiography
if the condition deteriorates so that balloon angiography, bypass surgery,
or reperfusion therapy may be initiated. Dissecting aneurysm is revealed by
CT scan or MRI of the chest.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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