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Diagnostic Tests for Chest pain
Chest pain: Diagnostic Tests
The list of diagnostic tests mentioned in various sources as used in the diagnosis of Chest pain includes:
- Physical exam
- Blood tests
- ECG
- X-rays
- Scans
Home Diagnostic Testing
These home medical tests may be relevant to Chest pain:
- High Blood Pressure: Home Testing
- Heart Health: Home Testing:
- Nerve Neuropathy: Related Home Testing:
Diagnosis of Chest pain: medical news summaries:
The following medical news items are relevant to diagnosis of Chest pain:
- Cardiac Syndrome X is a difficult to diagnose heart condition
- Familial hypercholesterolemia
- Heart transplant has a good prognosis despite difficult journey
- Increasing awareness of cancer symptoms by doctors and patients may improve diagnosis
- More news »
Diagnostic Tests for Chest pain: Online Medical Books
16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the diagnostic tests for Chest pain.
FLANK PAIN:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine tests include a CBC, sedimentation rate, chemistry panel, urinalysis, and urine culture. An intravenous pyelogram is the next logical step. If these fail to make a definitive diagnosis, one should consider ordering an abdominal ultrasound or a CT scan of the abdomen. If a renal infarction is suspected, aortography and renal angiography may be ordered. When the above tests are all negative, one should consider x-rays of the lumbosacral spine and MRI of the thoracic and lumbar spine. Consulting a urologist is prudent before ordering expensive diagnostic tests.
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
CHEST PAIN:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
All patients should have a CBC, sedimentation rate, chemistry panel, VDRL test, chest x-ray, and EKG. If there is sputum, a smear and culture should be done as soon as possible.
If a myocardial infarction is suspected, then serial EKGs and tests for the isoenzyme of creatine kinase (CK-MB) should be done if the initial EKG and enzymes do not show any significant changes. Serum cardiac troponin levels may also be diagnostic of a myocardial infarct. Thallium-201 scintigraphy is useful in diagnosing both myocardial infarction and coronary insufficiency. Exercise tolerance tests may help diagnose coronary insufficiency. Immediate coronary angiography should be undertaken if the condition deteriorates. This can be followed by immediate balloon angioplasty, reperfusion therapy, or bypass surgery.
If a pulmonary embolism is suspected, arterial blood gases and a ventilation-perfusion scan should be done. d -dimer testing of whole blood is a sensitive test of pulmonary embolus. Pulmonary angiography may need to be done if these are negative and pulmonary embolism is still strongly suspected.
If esophageal disease is suspected, an upper GI series with esophagogram should be done; this can be followed with esophagoscopy and gastroscopy if needed. A Bernstein test (acid perfusion of the esophagus) may reproduce the exact pain and distinguish esophageal reflux from a cardiac source of the pain. Ambulatory pH monitoring may also diagnose reflux esophagitis.
If pericarditis is suspected, echocardiography and possibly a CT scan of the chest and pericardium may be necessary. Coronary angiography may be necessary to diagnose coronary insufficiency. Echocardiography is also helpful in diagnosing mitral valve prolapse and the various myocardiopathies. Twenty-four-hr Holter monitoring is useful in diagnosing many causes of intermittent chest pain.
Referral to a cardiologist or pulmonologist may be appropriate at any point in this workup. Dissecting aneurysm may be confirmed by a CT scan or MRI of the chest.
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Chest expansion, asymmetrical:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If you don't suspect flail chest and if the patient isn't experiencing acute respiratory distress, obtain a brief history. Asymmetrical chest expansion commonly results from mechanical airflow obstruction, so find out if the patient is experiencing dyspnea or pain during breathing. If so, does he feel short of breath constantly or intermittently? Does the pain worsen his feeling of breathlessness? Does repositioning, coughing, or other activity relieve or worsen the patient's dyspnea or pain? Is the pain more noticeable during inspiration or expiration? Can he inhale deeply?
Ask if the patient has a history of pulmonary or systemic illness, such as frequent upper respiratory tract infections, asthma, tuberculosis, pneumonia, or cancer. Has he had thoracic surgery? (This typically produces asymmetrical chest expansion on the affected side.) Also, ask about blunt or penetrating chest trauma, which may have caused pulmonary injury. Obtain an occupational history to find out if the patient may have inhaled toxic fumes or aspirated a toxic substance.
Next, perform a physical examination. Begin by gently palpating the trachea for midline positioning. (Deviation of the trachea usually indicates an acute problem requiring immediate intervention.) Then examine the posterior chest wall for areas of tenderness or deformity. To evaluate the extent of asymmetrical chest expansion, place your hands — fingers together and thumbs abducted toward the spine — flat on both sections of the lower posterior chest wall. Position your thumbs at the 10th rib, and grasp the lateral rib cage with your hands. As the patient inhales, note the uneven separation of your thumbs, and gauge the distance between them. Then repeat this technique on the upper posterior chest wall. Next, use the ulnar surface of your hand to palpate for vocal or tactile fremitus on both sides of the chest. To check for vocal fremitus, ask the patient to repeat “99” as you proceed. Note asymmetrical vibrations and areas of enhanced, diminished, or absent fremitus. Then percuss and auscultate to detect air and fluid in the lungs and pleural spaces. Finally, auscultate all lung fields for normal and adventitious breath sounds. Examine the patient's anterior chest wall, using the same assessment techniques.
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Flank pain:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient’s condition isn’t critical, take a thorough history. Ask about the pain’s onset and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.
Ask the patient about changes in his normal pattern of fluid intake and urine output. Explore his history for a urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.
During the physical examination, palpate the patient’s flank area and percuss the CVA to determine the extent of pain.
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Chest pain:
History and physical examination
(Handbook of Signs & Symptoms (Third 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, 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. (See Chest pain: Common causes and associated findings, pages 136 and 137.)
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Chest expansion, asymmetrical:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If you don’t suspect flail chest and if the patient isn’t experiencing acute respiratory distress, obtain a brief history. Asymmetrical chest expansion commonly results from mechanical airflow obstruction, so find out if the patient is experiencing dyspnea or pain during breathing. If so, does he feel short of breath constantly or intermittently? Does the pain worsen his feeling of breathlessness? Does repositioning, coughing, or any other activity relieve or worsen the patient’s dyspnea or pain? Is the pain more noticeable during inspiration or expiration? Can he inhale deeply?
Ask if the patient has a history of pulmonary or systemic illness, such as frequent upper respiratory tract infections, asthma, tuberculosis, pneumonia, or cancer. Has he had thoracic surgery? (This typically produces asymmetrical chest expansion on the affected side.) Also, ask about blunt or penetrating chest trauma, which may have caused pulmonary injury. Obtain an occupational history to find out if the patient may have inhaled toxic fumes or aspirated a toxic substance.
Next, perform a physical examination. Begin by gently palpating the trachea for midline positioning. (Deviation of the trachea usually indicates an acute problem requiring immediate intervention.) Then examine the posterior chest wall for areas of tenderness or deformity. To evaluate the extent of asymmetrical chest expansion, place your hands—fingers together and thumbs abducted toward the spine—flat on both sections of the lower posterior chest wall. Position your thumbs at the 10th rib, and grasp the lateral rib cage with your hands. As the patient inhales, note the uneven separation of your thumbs, and gauge the distance between them. Then repeat this technique on the upper posterior chest wall. Next, use the ulnar surface of your hand to palpate for vocal or tactile fremitus on both sides of the chest. To check for vocal fremitus, ask the patient to repeat “99” as you proceed. Note any asymmetrical vibrations and areas of enhanced, diminished, or absent fremitus. Then percuss and auscultate to detect air and fluid in the lungs and pleural spaces. Finally, auscultate all lung fields for normal and adventitious breath sounds. Examine the patient’s anterior chest wall, using the same assessment techniques.
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Flank pain:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient’s condition isn’t critical, take a thorough history. Ask about the pain’s onset and apparent precipitating events. Have him describe the pain’s location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.
Ask the patient about any changes in his normal pattern of fluid intake and urine output. Explore his history for urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.
During the physical examination, palpate the patient’s flank area and percuss the CVA to determine the extent of pain.
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
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.)
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Chest Pain, Atypical:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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).
Testing
A. Probability of IHD based on history. Prior to testing, the probability of IHD can be inferred by the estimates made by Diamond and Forrester (3). Examples of these estimates include (a) high probability situations (probability > 75%)—men aged more than 40 years and women aged more than
50 years with typical anginal symptoms; (b) moderate probability situations (probability > 50%)—men aged more than 40 years and women aged more than 60 years with atypical features; (c) low probability situations (probability < 20%)—men aged less than 40 years and women aged less than 50 with atypical features.
B. Response to nitroglycerin (NTG). Response of chest pain to sublingual NTG can be used (with caution) as an adjunct for determining whether a patient’s chest pain is from IHD. For example, a prompt response (< 3 minutes) increases the probability of IHD; however, it should be noted that esophageal spasm and biliary colic may also respond favorably to this intervention. Conversely, failure to respond to NTG should not be used to exclude the possibility of IHD.
C. Response to a gastrointestinal (GI) cocktail. It is common practice in many emergency room and urgent care settings to give a patient a GI cocktail that typically contains a liquid antacid, xylocaine, and an antispasmodic. No reliable studies exist on the diagnostic accuracy of this intervention.
D. Resting ECG. A normal resting ECG cannot be used as the sole criterion to rule out the presence of ischemic heart disease.
E. Exercise testing. The standard provocative test for patients with atypical chest pain who have at least a moderate risk for IHD is the exercise treadmill test. During exercise, the patient is monitored for symptoms of chest pain, heart rate, blood pressure response to exercise, arrhythmias, and ST-segment changes. A significant test includes an ST-segment depression of at least
1.0 mm below the baseline. It is important that the patient achieve a vigorous heart rate response to exercise. Approximately 20% of patients with an abnormal exercise tolerance test (ETT) have significant ST-segment changes occurring only at maximal or near-maximal heart rate changes. Therefore, when reviewing an ETT report, if the maximal heart rate achieved was less than 85% of the predicted heart rate, the results of the test should be interpreted more cautiously.
F. Other diagnostic tests. Some patients should not undergo the standard ETT for a number of reasons. These include the inability to exercise because of gait or instability problems and underlying ECG abnormalities that make the standard ETT unreadable (e.g., left ventricular hypertrophy with strain and left bundle branch block). If the patient is able to exercise, the preferred test will be either an exercise echocardiogram or an exercise thallium test. If the patient is unable to exercise, test options include a dobutamine echocardiogram and a dipyridamole (Persantine) thallium test. A divergence of opinion is seen as to which of these tests is best; however, each has higher sensitivity and specificity than the standard ETT.
Diagnostic assessment
The key to the diagnosis of atypical chest pain remains in the clinical history. An assessment of the probability of ischemic heart disease should be made on all patients. Those with a very low probability of IHD should not undergo diagnostic testing because, given the problems of sensitivity and specificity, the results will have little or no impact on the management of the patient. Critical pathways for triage have been proposed to help identify intermediate and high risk patients (4,5).
References
1. Panju AA, Hemmelgard BR, Guyatt GH, Simel DL. Is this patient having a myocardial infarction? JAMA 1998;280:1256–1263.
2. American College of Emergency Physicians. Clinical policy for the initial approach to adults presenting with a chief complaint of chest pain, with no history of trauma. Ann Emerg Med 1995;25:274–299.
3. Diamond GA, Forrester JS. Analysis of probability as an aid in the clinical diagnosis of coronary-artery disease. N Engl J Med 1979;300:1350–1358.
4. Nichol G, Walls R, Goldman L, et al. A critical pathway for management of patients with acute chest pain who are at low risk for myocardial ischemia: recommendations and potential impact. Ann Intern Med 1997;127:996–1005.
5. Braunwald E, Mark DB, Jones RH. Diagnosing and managing unstable angina: quick reference guide for clinicians, Number 10. AHCPR Publication No.94-0603. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute; 1994.>>>>
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Chest Pain, Substernal:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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.
Testing
A. ECG. Despite the availability of a number of tests, the history remains very important in determining the likelihood of CAD in a patient with substernal chest pain. It is important to avoid using a normal ECG as “rule out” criteria, as many patients with unstable angina or even an acute MI may initially have a normal ECG. The diagnosis of CAD can be based on characteristic changes in the ST-T wave morphology during a symptomatic episode. Specifically, ST segment elevation greater than or equal to 1 mm in two or more consecutive leads is highly suggestive of an acute MI and is associated with the highest morbidity and mortality rate (3). ST segment depression of greater than or equal to 1 mm or T-wave inversion in two or more contiguous leads also strongly suggests ischemia or acute MI. The presence of Q waves greater than or equal to 0.04 seconds indicates previous MI. However, Q waves occurring in lead III alone may be a normal finding. As patients with initially normal ECG are still at risk for life-threatening complications and death (3% and 1%, respectively), it is important to follow serial ECGs for any evolution (3).
B. Creatinine kinase. The most widely used laboratory test for the detection of MI is the creatinine kinase enzyme. The isoenzyme, CK-MB, is abundant in the myocardium and, therefore, is sensitive and specific for myocardial injury. With acute MI, the MB fraction typically begins to rise within 6 hours of symptom onset, peaks at 18 hours, and falls after 24 hours. Total CK and CK-MB should be measured every 6 to 8 hours for a 24-hour period.
C. Troponin I and T. Both troponin I and T proteins are located on the contractile apparatus of the myocardium. These proteins are highly sensitive for myocardial injury. The prospective study conducted by Hamm et al. showed that in the 47 patients diagnosed with acute MI, 94% were positive for troponin T and 100% for troponin I (4). In addition, the negative predictive value of troponin T was 98.9% and that of troponin I was 99.7% (4).
D. Noninvasive and invasive testing. Both exercise and pharmacologic stress tests are used to assess for CAD in patients with stable angina. Unstable angina, uncontrolled hypertension, severe aortic stenosis, unstable arrythmias, and recent MI (4–6 weeks) are contraindications to stress testing.
1. Exercise ECG is a relatively inexpensive test with an overall sensitivity and specificity of 50% to 70%. It is most useful for those patients with a moderate pretest probability. Protocols are used to incrementally increase treadmill speed and elevation until the maximal heart rate for age is achieved. The ECG is monitored for ST depression and any ventricular arrythmias. The patient is also monitored for any fall in blood pressure or complaints of chest discomfort or dyspnea.
2. Exercise ECG with thallium or technetium sestamibi. The use of these radioisotopes improves the sensitivity and specificity of exercise ECG to approximately 90%. Thallium is distributed in proportion to blood flow. Areas of decreased uptake during exercise followed by normal uptake at rest suggest ischemia, whereas areas of persistent defect indicate infarction. Technetium is a newer agent with the advantage of a slow washout and added contrast, which results in fewer false-positive findings than thallium.
3. Exercise echocardiogram. This method detects wall motion abnormalities during exercise and has comparable sensitivity and specificity to exercise ECG. It is preferred in patients with abnormal resting ECGs and in patients with a low pretest probability. The disadvantages include difficulty imaging obese patients and the need to image as close to peak exercise as possible.
4. Dipyridamole or adenosine stress testing. The use of intravenous coronary vasodilators (dipyridamole or adenosine) in combination with a radioisotope (thallium or technetium sestamibi) is useful in patients who are unable to exercise. Areas of redistribution suggest ischemia, whereas areas of persistent defects indicate infarction. The use of phosphodiesterase inhibitors and the presence of reactive airway disease are contraindications.
5. Dobutamine echocardiogram. This method is also used for those who are unable to exercise. Dobutamine increases myocardial oxygen demand by increasing contractility and essentially “exercises” the heart. The echo monitors for any wall motion abnormalities.
6. Coronary angiography. Considered the “gold standard” test, this procedure provides the most detailed structural information of all the tests discussed. It is indicated in those patients who are at high risk for CAD by noninvasive tests and for those with persistent symptoms despite medical therapy. As diagnosis is closely tied to therapy, only those patients who are candidates for invasive procedures (e.g., percutaneous transluminal coronary angioplasty or coronary artery bypass graft) should be considered.
Diagnostic assessment
In patients presenting with substernal chest pain, the key to diagnosis involves quickly and accurately assessing for the likelihood of myocardial ischemia or infarction. An initial history, physical examination, and ECG will help in the risk assessment of the patient for significant CAD. Those who are at high to intermediate risk need to then be evaluated for presence of unstable angina. Once established, further steps involve the simultaneous evaluation with serial ECGs and enzymes along with therapy to reduce ischemia. Cardiac angiography is the final step in evaluation and treatment. For those at low risk for CAD and not meeting criteria for unstable angina, further evaluation involves noninvasive diagnostic testing with the possibility for cardiac angiography and revascularization.
References
1. Braunwald E, Mark DB, Jones RH. Unstable angina: diagnosis and management. Clinical Practice Guideline Number 10. AHCPR Publication No. 94-0602. Rockville, MD: Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute, Public Health Service, US Department of Health and Human Services, March 1994.
2. Anderson KM, Wilson PWF, Odell PM. An updated coronary risk profile. A statement for health professionals. Circulation 1991;83:356–362.
3. Karlson BW, Hallgren HP, Liliequist JA. Emergency room prediction of mortality and severe complication in patients with suspected acute myocardial infarction. Eur Heart J 1994;15:1558–1565.
4. Hamm CW, Goldmann BU, Heeschen C. Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I.
N Engl J Med 1997;337:1648–1653.>
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Flank Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Renal pain occurs with stretching of the capsule and distension of the collecting system. The pain is usually severe and aching, with nausea, vomiting, and ileus. There may be hyperesthesia in the T 9 to 10 dermatome.
Ureteral pain begins in the costovertebral angle and radiates to the lower abdomen, upper thigh, testis, or labia. The pain is excruciating, with crescendo waves of colic. The patient writhes but is unable to obtain relief. Hyperesthesia over the T 12 dermatome often occurs along with tenderness over the kidney or ureter.
Source: Field Guide to Bedside Diagnosis, 2007
Acute Nonpleuritic Chest Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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.
Source: Field Guide to Bedside Diagnosis, 2007
Pleuritic Chest Pain:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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).
Source: Field Guide to Bedside Diagnosis, 2007
Chest expansion, asymmetrical:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin a physical examination by gently palpating the trachea for midline positioning. (Deviation of the trachea usually indicates an acute problem requiring immediate intervention.) Then examine the posterior chest wall for areas of tenderness or deformity. To evaluate the extent of asymmetrical chest expansion, place your hands — fingers together and thumbs abducted toward the spine — flat on both sections of the lower posterior chest wall. Position your thumbs at the 10th rib, and grasp the lateral rib cage with your hands. As the patient inhales, note the uneven separation of your thumbs, and gauge the distance between them. Then repeat this technique on the upper posterior chest wall.
CULTURAL CUE:Chest size varies with race, ultimately affecting respiratory function. Whites tend to have larger chests and lung capacities than Blacks, Asians, and Native Americans.
Next, use the ulnar surface of your hand to palpate for vocal or tactile fremitus on both sides of the chest. To check for vocal fremitus, ask the patient to repeat “99” as you proceed. Note any asymmetrical vibrations and areas of enhanced, diminished, or absent fremitus. Then percuss and auscultate to detect air and fluid in the lungs and pleural spaces. Finally, auscultate all lung fields for normal and adventitious breath sounds. Examine the patient’s anterior chest wall, using the same assessment techniques.
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Flank pain:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
During the physical examination, palpate the patient’s flank area and percuss the CVA to determine the extent of pain.
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Chest pain:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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, 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.
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Chest Pain:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Chest expansion, asymmetrical:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If you don't suspect flail chest or tension pneumothorax and if the patient isn't experiencing acute respiratory distress, obtain a brief history. Asymmetrical chest expansion commonly results from mechanical airflow obstruction, so find out if the patient is experiencing dyspnea or pain during breathing. If so, does he feel short of breath constantly or intermittently? Does the pain worsen his feeling of breathlessness? Does repositioning, coughing, or other activity relieve or worsen the patient's dyspnea or pain? Is the pain more noticeable during inspiration or expiration? Can he inhale deeply?
Ask if the patient has a history of pulmonary or systemic illness, such as frequent upper respiratory tract infections, asthma, tuberculosis, pneumonia, or cancer. Has he had thoracic surgery? (This typically produces asymmetrical chest expansion on the affected side.) Also ask about blunt or penetrating chest trauma, which may have caused pulmonary injury. Obtain an occupational history to find out if the patient may have inhaled toxic fumes or aspirated a toxic substance.
Next, perform a physical examination. Begin by gently palpating the trachea for midline positioning. (Deviation of the trachea usually indicates an acute problem requiring immediate intervention.) Then examine the posterior chest wall for areas of tenderness or deformity. To evaluate the extent of asymmetrical chest expansion, place your hands—fingers together and thumbs abducted toward the spine—flat on both sections of the lower posterior chest wall. Position your thumbs at the 10th rib, and grasp the lateral rib cage with your hands. As the patient inhales, note the uneven separation of your thumbs, and gauge the distance between them. Then repeat this technique on the upper posterior chest wall. Next, use the ulnar surface of your hand to palpate for vocal or tactile fremitus on both sides of the chest. To check for vocal fremitus, ask the patient to repeat “99” as you proceed. Note asymmetrical vibrations and areas of enhanced, diminished, or absent fremitus. Then percuss and auscultate to detect air and fluid in the lungs and pleural spaces. Finally, auscultate all lung fields for normal and adventitious breath sounds. Examine the patient's anterior chest wall, using the same assessment techniques.
Source: Nursing: Interpreting Signs and Symptoms, 2007
Flank pain:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient's condition isn't critical, take a thorough history. Ask about the onset of his pain and apparent precipitating events. Have him describe the pain's location, intensity, pattern, and duration. Find out if anything aggravates or alleviates it.
Ask the patient about changes in his normal pattern of fluid intake and urine output. Explore his history for a urinary tract infection (UTI) or obstruction, renal disease, or recent streptococcal infection.
During the physical examination, palpate the patient's flank area and percuss the CVA to determine the extent of pain.
Source: Nursing: Interpreting Signs and Symptoms, 2007
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.
Source: Nursing: Interpreting Signs and Symptoms, 2007
Chest Pain - Case 14-1: 17-Year-Old Boy:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
IV. Diagnostic Studies
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Chest Pain - Case 14-2: 15-Year-Old Boy:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
IV. Diagnostic Studies
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Chest Pain - Case 14-3: 20-Year-Old Boy:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
IV. Diagnostic Studies
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Chest Pain - Case 14-4: 17-Year-Old Boy:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
IV. Diagnostic Studies
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Chest Pain - Case 14-5: 3-Year-Old Girl:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
IV. Diagnostic Studies
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
Chest Pain - Case 14-6: 15-Year-Old Boy:
III. Physical Examination
(Pediatric Complaints and Diagnostic Dilemmas)
IV. Diagnostic Studies
Source: Pediatric Complaints and Diagnostic Dilemmas, 2003
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