Diagnosis of Pulmonary heart disease

Diagnostic Tests for Pulmonary heart disease: Online Medical Books

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CHEST PAIN: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is the chest pain acute or chronic? If it is acute, one must consider acute myocardial infarction, pulmonary embolism, pneumothorax, pericarditis, and fractures. If the chest pain is chronic, one must consider chronic coronary insufficiency, esophagitis, hiatal hernia, and various chest wall conditions.
2. Is the pain constant or intermittent? Constant pain suggests acute myocardial infarction, pulmonary infarction, dissecting aneurysm, and pneumonia. Intermittent pain would suggest coronary insufficiency, Tietze's disease, and DaCosta's syndrome.
3. Is there associated significant hypertension? Significant hypertension would make one think of dissecting aneurysm, but it is also found occasionally in acute myocardial infarction.
4. Is the pain relieved by antacids? Relief by antacids should prompt one to consider esophagitis and hiatal hernia.
5. Is the pain precipitated or increased by breathing? The pain of pleurisy, costochondritis, rib fractures, and pneumothorax is precipitated or increased by breathing.
6. Is there associated hemoptysis? Hemoptysis should make one consider a pulmonary embolism.
7. Is there fever and purulent sputum? Fever and purulent sputum should make one consider pneumonia.
8. Is there dyspnea? Dyspnea should make one consider pneumothorax, pulmonary embolism, and pneumonia, as well as congestive heart failure secondary to acute myocardial infarction.
9. Is it aggravated by movement? Aggravation of the chest pain by movement should suggest pericarditis. Remember, myocardial infarctions may also have extension into the pericardium and must be considered at times.
10. Is it relieved by nitroglycerin? Relief by nitroglycerin should suggest a coronary insufficiency, but esophagospasm may be relieved by nitroglycerin also.

DIAGNOSTIC WORKUP

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.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Chest Pain: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Cardiovascular etiologies
  –Myocardial infarction
  –Angina
  –Acute coronary syndrome
  –Pulmonary embolus
  –Pericarditis
  –Arrhythmias
  –Mitral valve prolapse
  –Aortic stenosis
  –Aortic dissection
  –Cardiac tamponade
• Pulmonary etiologies
  –Pneumonia
  –COPD
  –Asthma
  –Pneumothorax
  –Tension pneumothorax
  –Hemothorax
  –Empyema
  –Pneumomediastinum
  –Lung cancer
• Gastrointestinal etiologies
  –Esophagitis/GERD
  –Gastritis
  –Peptic ulcer disease
  –Perforated ulcer
  –Esophageal spasm
  –Pancreatitis
  –Esophageal rupture
  –Pneumoperitoneum
• Musculoskeletal etiologies
  –Muscle strain or spasm
  –Intercostal muscle spasm
  –Costochondritis
  –Trauma (e.g., rib fracture)
• Zoster
• Cancer (e.g., lymphoma)
• Panic disorder
• Less common etiologies include Tietze's syndrome, Pott's disease (tuberculosis of the spine), xyphodenia, cholecystitis, peritonitis, liver cancer, and hepatitis

Workup and Diagnosis

• History and physical examination
  –Assess onset, duration, location, radiation, type of pain, and exacerbating and alleviating factors
  –Cardiovascular evaluation includes assessment of heart sounds, murmurs, gallops or rubs, and carotid bruit
  –All patients require a rectal exam (e.g., to assess for occult bleeding due to GI etiologies, to assess for occult bleeding before initiating anticoagulation)
  –Risk factors for coronary artery disease include smoking, hyperlipidemia, diabetes, and a personal or family history of coronary artery disease
• Initial evaluation may include pulse oximetry, CBC, electrolytes, BUN/creatinine, calcium, glucose, PT/INR/PTT, ECG, chest X-ray, and cardiac enzymes
• Patients with suspected coronary artery disease may require stress testing, echocardiogram, and/or cardiac catheterization
• Further studies to consider include arterial blood gas, liver function tests, amylase and lipase, CT of chest and abdomen, VQ scan, peak flow testing and pulmonary function tests, arteriogram, bronchoscopy, EGD, and/or esophagram
• Transesophageal echocardiogram and/or CT scan or MRI of the chest may be required to rule out aortic dissection (if widened mediastinum is present on X-ray)

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Source: In a Page: Signs and Symptoms, 2004

Chest Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Musculoskeletal
  –Sharp, stabbing pain that is usually very well localized, often worsened by deep breath or cough
  –Costochondritis: Tender parasternal pain at insertion of ribs into cartilage en route to sternum; increases with palpation or mild chest compression (possibly postviral)
  –Injury to chest wall

• Pulmonary
  –Very common cause, usually associated with respiratory symptoms: Shortness of breath, cough, exercise intolerance
  –Asthma (most common), often only EIA; may have personal/family history of atopy (asthma, eczema, seasonal allergies); shortness of breath is usually primary complaint, with feeling of chest tightness/pain as a secondary symptom
  –Pleuritic chest pain: Sharp, stabbing pain with deep breaths, indicates pleural space inflammation, probably postinfectious (especially viral)
  –Pneumonia: Chest pain secondary to cough or pleural involvement
  –Pneumothorax can occur spontaneously, especially in tall, thin athletes

• Gastrointestinal
  –GERD and PUD: Burning, substernal pain with eating, worse at night
  –Rarely pancreatitis (with back pain too), cholecystitis, hiatal hernia, hepatitis

• Cardiac: Rare in children
  –Precordial catch syndrome: Sharp, brief (seconds) chest pain usually associated with rising from lying or sitting; unclear etiology, but of no significance
  –Pericarditis: Inflammation of the pericardium; often postviral, may represent connective tissue/autoimmune, cancer, bacterial infection (very ill appearing with fever), or post-cardiac surgery; patients often lean forward to decrease the pain
  –MI (rare): Congenital coronary anomaly, post-Kawasaki, cocaine use, hypertrophic cardiomyopathy
  –Aortic dissection: Consider if features or history of Marfan syndrome is present

Workup and Diagnosis

• History
  –Activity at onset, (chest pain with exercise is a red flag!), precipitating/relieving factors, quality of pain (sharp vs dull)
  –Associated symptoms (shortness of breath, diaphoresis, cough/wheeze, nausea/vomiting), recent illness, response to eating, sleeping, different foods (caffeine, chocolate, spicy, or high-fat foods)
  –Personal/family history of asthma, allergies, eczema
  –Recent diagnosis of heart disease or death in a family member often generates fear in the patient or parent, prompting the evaluation of chest pain
  –Social history: Recent life stressors (school problems, family discord, etc.); drug use, especially cocaine
• Physical exam
  –Reproducible with palpation likely musculoskeletal
  –Chest exam: Wheezing, rales, crepitus
  –Cardiac exam: Usually normal, even with cardiac causes; pericarditis is associated with rub
• Chest X-ray for infiltrates, pneumonia, pneumothorax
• ECG and cardiac enzymes are rarely required but relatively inexpensive and readily available, and can rule out MI and provide reassurance for families
• Cardiac stress test
  –Continuous ECG monitoring while the patient exercises to evaluate for coronary insufficiency
  –Used for patients with exercise-induced chest pain and/or coronary abnormalities

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Source: In A Page: Pediatric 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. Once 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 infarct. 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.

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Source: Differential Diagnosis in Primary Care, 2007

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.)

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Source: Handbook of Signs & Symptoms (Third 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.)

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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

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

 » Next page: Signs of Pulmonary heart disease

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