Diagnosis Wikidoc: Chest Pain no ST elevation
There are 4 other Life Threatening Diseases to Exclude Immediately:

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

# 2. Pulmonary Embolism
- Supportive symptoms include:
Shortness of breath
Chest pain
Dyspnea
Anxiety
Pleuritic chest pain
- Shortness of breath
- Chest pain
- Dyspnea
- Anxiety
- Pleuritic chest pain
- Supportive laboratory studies include:
D-dimers are formed by the degradation of fibrin clot.
Almost all patients with PE have some endogenous fibrinolysis, and therefore have elevated levels of D-dimer.
Many other processes, such as pneumonia, congestive heart failure (CHF), myocardial infarction (MI), malignancy, and surgery, are also associated with a mild degree of fibrinolysis, and hence an elevated D-dimer is not specific for pulmonary embolism.
Its negative predictive value, however, is 91  94%
- D-dimers are formed by the degradation of fibrin clot.
- Almost all patients with PE have some endogenous fibrinolysis, and therefore have elevated levels of D-dimer.
- Many other processes, such as pneumonia, congestive heart failure (CHF), myocardial infarction (MI), malignancy, and surgery, are also associated with a mild degree of fibrinolysis, and hence an elevated D-dimer is not specific for pulmonary embolism.
- Its negative predictive value, however, is 91  94%
- Next study to do:
Spiral CT scanning is now a standard modality to non-invasively diagnose PE.
Initial studies reported sensitivities for diagnosing emboli to the segmental level (4th order branch) as high as 98%
- Spiral CT scanning is now a standard modality to non-invasively diagnose PE.
- Initial studies reported sensitivities for diagnosing emboli to the segmental level (4th order branch) as high as 98%

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

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

# Other conditions to Consider

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

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

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

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

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