Common Clinical Problems:
What do I think this is?
Is there anything else this could be?
What doesn’t fit?
Chest pain: History
You are on call on the first night of your
medicine rotation. Your team is called to
Radiology to assess a 41 year old man who
complained of chest discomfort 10 minutes ago
in the CT scanner, where he was having a CT to
assess the response of his metastatic colon
cancer to chemotherapy.
What is the most likely diagnosis?
2. Aortic dissection
Prevalence in ED patients with Chest
Unstable angina, MI 16-28%
Aortic dissection .003%
Request ECG and monitor
He describes the pain as substernal, sharp, 3/10
and radiating to both shoulders.
The pain is not pleuritic.
There is no associated dyspnea or nausea, but he
has had some sweating.
His medical history is notable for Stage 4 colon
cancer, metastatic to the liver and lungs,
resected and being treated with chemo. He also
has hypertension, hyperlipidemia, and DM2.
Which feature of his history would
most increase the likelihood of ACS?
1. Pain radiating to both
2. Described as sharp
History in acute MI
Increases likelihood of AMI
Pain radiating to R arm >both arms> L arm
Decreases likelihood of AMI
Reproduced by palpation, sharp or stabbing, or
Chest pain that responds to
nitroglycerin is cardiac in origin
If chest pain improves with nitro, it
What else could this be??
Common sources of diagnostic error
The diagnosis that springs to mind: the last
lecture you attended or the last patient you saw
Stop thinking about alternate diagnoses once a
reasonable cause of symptoms is considered
A 72 year old man with a history of diabetes,
hypertension and smoking is brought to the
ER with sudden, severe chest pain radiating
to the back of 25 minutes duration.
High mortality (aortic dissection 1% per hour)
Treatable early (with early surgery, survival
20%+ still missed on initial evaluation
What are we talking about?
Aortic dissection: History
Tearing or ripping chest pain (LR 10.8)
Migrating chest and back pain (LR 7.6)
Sudden onset pain
Aortic Dissection: Exam
Any “classic” finding present in only half of all
Diastolic murmur (aortic insufficiency)
Unequal blood pressure in limbs (> 20 mm Hg)
Elevated JVP (tamponade)
Focal neuro deficit
Chest x-ray findings
Overall sensitivity 90%
Widened mediastinum (Sn ~ 65%)
Abnormal aortic contour (Sn ~ 70%)
Pleural effusion (Sn ~ 15%)
Consider aortic dissection:
Sudden, tearing, or ripping chest pain,
especially with radiation to back
Migrating chest, back abdominal pain
Neuro deficit, pulse deficit, new AI murmur,
ECG without ST changes in patient you
thought was having an MI
An 83 year old man with a remote history of a
liposarcoma of the arm presents with 4 days
of fatigue, increasing dyspnea, and chest
Temperature - C 36.6 degC
Heart Rate 100 bpm High
Respiratory Rate 14 br/min
SBP - Noninvasive 155 mmHg High
DBP - Noninvasive 83 mmHg
Hypothesis driven physical exam
126 97 23 |- Ca 8.2 --- --- --- |- Ca - -
---------|-------------|------------< 111 |- Mg 2.0 ---------|-------------|------------< - - - |- Mg - -
4.7 22 0.74 |- Phos - - - --- --- --- |- Phos
12.9 |- PT 13.7 --- |- PT - - -
1.30 ]----------------------[ 255 |- INR 1.1 - - - ]----------------------[ - - - |- INR - - -
36 |- PTT 30 --- |- PTT - - -
Temperature - C 37 degC
Heart Rate 115 bpm High
Respiratory Rate 20 br/min
SBP - Noninvasive 102 mmHg
DBP - Noninvasive 62 mmHg
SpO2 95 %
“The patient appears to be in moderate distress, ill
appearing, laying in bed with an elevated rr and
cool washcloth on his forehead.”
Which finding would you seek next?
1. Pulsus alternans
2. Pulsus paradoxus
3. Pulsus parvus et
Fluid increases intrapericardial pressure
With inspiration, venous return to R
ventricle increases; it encroaches onto LV
Symptoms & signs of poor cardiac output
Tachycardia then hypotension
Increased venous return with inspiration
Increased fluid in pericardial space restricts
the ability of RV to stretch; excess venous
return presses on ventricular septum
Decreased LV filling
Decreased blood pressure with inspiration
Also seen with severe asthma
Inflate BP cuff to above systolic BP and come
down veeeerrrrry slowly
Note the pressure at which you begin to hear
Korotokoff sounds during expiration
Decreased very slowly
Note the pressure at which you hear sounds
in inspiration and expiration
> 10 mm Hg is abnormal
During the hospitalization he again had negative
troponins, also negative HIV, and negative
QuantiFERON. The pericardial fluid had 482 white
cells with 77% neutrophils and 11% lymphocytes.
RBC count was less than 3000. Gram stain culture,
AFB, fungal were all negative from pericardial fluid.
Acute Chest Pain: Next diagnostic
Further imaging as guided by history and
Echo to assess wall motion or pericarditis?
CTA or TEE or MRI to assess for dissection?
Suggestive of non-cardiac chest pain
Lasting seconds at a time
Lasting hours or days at a time
Unchanged by exertion
Associated with waterbrash (acid in mouth)
ACS Pericarditis Noncardiac
Hx SSCP/L-sided SSCP Anterior chest pain Any location
”Pressure” Radiation to back Often pleuritic ”Sharp”
Exertional ”Sharp”, “Tearing” Better with leaning Pleuritic
Radiationarms, Neurologic deficits forward Increases with
neck, jaw Abrupt onset movement, palpation
Nausea Syncope Inciting event
Diaphoresis Preceding illness
Risk factors Hypertension Hypertension Recent URI Cough
Diabetes Older age SLE Trauma
FHx early CAD Connective tissue D/O Recent MI or cardiac Reflux
Tobacco use surgery
Exam Usually normal Any ‘classic’ finding Friction rub Tenderness to
Systolic murmur present in ~50% Distant heart sounds palpation
Gallop Diastolic murmur If tamponade: Step-offs
Elevated JVP Unequal pulses or blood - tachycardia
pressure (> 20 mm Hg)
Crackles - hypotension
- pulsus paradoxus
Transient loss of consciousness, with
associated loss of postural tone and
3% of ED visits and 1% of hospital
History and exam establish diagnosis in
About one-third remain unexplained
Key questions in syncope
Is this really syncope?
Seizure will typically have slower return to
baseline (postictal state)
Tongue biting, loss of bowel or bladder suggest
Syncope can be associated with tonic clonic
What’s most likely?
What can’t I miss?
Have you ever had syncope?
Neurocardiogenic AKA vasodepressor AKA
vasovagal syncope (25-65%)
Autonomic activation causes decreased BP,
bradycardia or both
Emotion, carotid sinus pressure, situational
Vasodilation, bradycardia, volume depletion
Orthostatic syncope (5-10%)
Must not miss
Major acute blood loss
Valvular disease (aortic or mitral stenosis)
Prodrome? Suggests neurocardiogenic - sudden
onset without prodrome suggests arrhythmia
Situation? Prolonged standing, physical or
emotional stress, cough, micturition, etc all suggest
neurocardiogenic. Syncope with exertion suggests
limited cardiac output (bad).
Position? Syncope while standing suggests
orthostasis, prolonged standing suggests
neurocardiogenic, supine suggests arrhthmia
Any chest pain or dyspnea?
History of cardiac disease?
Family history of cardiac disease or sudden death?
Include orthostatic VS
HEENT - tongue laceration suggests seizure
Cardiac - rate and rhythm, evidence of heart
failure, evidence of valvular disease
Lung - evidence of heart failure or PE
Neurologic - evidence of stroke