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Tx wall + chest pain Cheat Sheet (DRAFT) by

Thoracic Wall and Chest Pain

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Serious Disorders

Heart: Myocardial Infarc­tion, angina, perica­rditis (>15 mins angina pain = consider MI)
Great Vessels: Dissecting Aneurysm, Pulmonary Embolism, Pulmonary Infarc­tion, Pneumo­thorax, Pneumona, Pleurisy
Oesoph­agus: Oesoph­ageal Rupture, Oesoph­ageal Spasm, Oesoph­agitis
Subdia­phr­agmic Disorders: Gallbl­adder, Stomach, Duodenum, Pancreas, Subphrenic collection
Infect­ions: Herpes Zoster, Pleuro­dynia, Infective Endoca­rditis, Osteom­yel­itis, Discitis, Tuberc­ulosis, Epidural infections
- Malignancy (Back pain in elder person, unrele­nting back pain, night pain, rapidly increasing back pain, weight loss, fever, malaise, hx of cancer, neuro signs in LL)

Mechanical Pain

Pitfalls: Ischaemic Heart disease (inter­sca­pular pain)
Herpes Zoster
GI disorders
Penetr­ating duodenal Ulcer - lower tx back pain
Oesoph­ageal spasm
Refer: Persistant pain, Eviden­ce/­sus­picion of sinsiter cause (Cardi­ac/GI) , Signif­icant Idiopathic Scolio­sis­/ky­phosis

Tx Pain

- Defined as pain between superiorly by a transverse line through the tip of the T1 Spinous Process, Inferiorly by a transverse line through the tip of the spinous process of T12 and laterally by vertical lines to the most lateral margins of the ES muscles
- Divided into upper, middle and lower thirds

Causes

MSK chest pain
- Costoc­hon­dritis
- Muscle Strains
- Sterno­-costal dysfun­ction (2nd-7th joints)
- Lower Cx Dysfun­ction
- Upper tx dysfun­ction
Tx back pain
- Myofascial Pain Syndrome
- Muscul­oli­gam­entous Strains - poor posture
- Dysfun­ction of the lower Cx + Tx (inter­sca­pular)
Pain radiates from back to the front of the chest
- Vertebral Disorder - irritation of an interc­ostal nerve root
- Herpes Zoster
- TrP in interc­ostal Muscle

In Hx

- Neck and upper back pain = Cx spine
- Anterior Chest pain + Tx spine pain = IHD/Di­sse­ction of Tx aorta
- Penetr­ating injury - surgical, dental, cather­isa­tio­n/c­ann­ula­tio­n/self inject­ion­/injury = tx osteom­yel­itis, epidural abscess, discitis

COPD

- Chronic bronch­itis, emphysema or both
- Caused by smoking, occupa­tional exposure to noxious gases, Alpha 1 antitr­ypsin deficiency
- Airflow limita­tion, unlike asthma it is permanent
S&S: >35 yo + Hx of smoking and respir­atory symptoms: SOB on exertion, Cough + sputum produc­tion, Wheezing, frequent chest infect­ions, pursed lip breathing, increased RR, Increased use of accessory muscles of respir­ation, Underw­eight, Cyanosis, Hyperi­nfl­ation of the chest, Downward Displa­cement of liver, Prolonged forced expiratory time
Invest­iga­tions: Spirometry - Reduced FEV1 + reduced FEV1/FVC ratio
Manage­ment: To GP = Stop smoking, Pulmonary Rehab, Pneumo­coccal + influenza vaccine, Medica­tions - Bronch­odi­lator inhalers, steriors, antibi­otics and inhaled oxygen

Asthma

- Inflam­matory disease , interm­ittent and reversible obstru­ction of the airways:
- Spasm of the smooth muscle that pulls on the cartil­aginous support
- Excessive production of secretions and oedema
S&S: Wheezing, Coughing, SOB, Tightness /pain in the chest
Triggers: URTI, Cold Air, Exercise, Pollution, Animals, Time of the day (early morning)
Diagnosed by: Spirometry - measures PEFR - reduced FEV1 in the second PEF
Classi­fic­ations: >1 of the symptoms above/ Hx of atopic disorder, Family Hx of asthma­/atopic disorder, Widespread wheeze heard
Manage­ment: Medication (short­acting B2 Agonist - Salbut­amol, Long acting B2 agonist - Salmet­erol. Steroids, Leukot­riene receptor antago­nist, Oral Steroids), Asthma support groups, recognise when their asthma is bad

Lung Cancer

- Mainly Bronchial Carcinoma
- Can be small cell/n­on-­small cell
- Risks: Active­/pa­ssive cigarette smoking, increased age, industrial dust - asbestos, chromium, arsenic, iron oxides, radiation
- S&S: Cough, SOB, Chest pain, Haemop­tysis, Bone pain, Weight loss, Finger Clubbing, Fever, Weakne­ss,­Dys­phagia, Wheezing and stridor
Other S&S: Reccur­ent­/slowly resolving pneumonia, Pleural effusion, HPOA, Suprac­lav­icu­lar­/ax­illary lympha­den­opathy, Parane­opl­astic syndrome (hormones released by tumour cells)
Parane­opl­astic syndrome: Ataxia, dizziness, nystagmus, difficulty swallo­wing, loss of muscle tone , loss of fine motor skills, slurred speech, memory loss, vision problems, sleep distur­bances, dementia, seizures, sensory loss in the limbs
Hypert­rophic Pulmonary Osteoa­rth­rop­athy: HPOA, joint stiffness and severe pain in the wrists and ankles, clubbing, gynaec­omastia
Pancoast Tumour: Severe should­er/arm pain + Horner's syndrome

Pneumo­thorax

- Air trapped between lung and chest wall
- Young, thin men, Trauma­,Lung diseases, sponta­neous = Marfan's
S&S: Sudden, sharp stabbing pain on one side of the chest, SOB, Pain worse on inspir­ation , Tachyc­ardia, Reduction in breath sounds on affected side, Chest expansion reduced , Resona­nt/­hyp­err­esonant percussion
- Tension Pneumo­thorax - Rare compli­cation - volume + pressure of the pneumo­thorax increases due to the tear acting as a one way valve. Puts pressure on lungs and heart - +ve medias­tinal shift

Pleural Effusion

- Collection of fluid within pleural space
Transu­dation: Accumu­lation of fluid due to excess fluid
Exudation of fluid: Inflam­mation - increased vascular permea­bility
S&S: SOB, Pleuritic chest pain, Breath sounds absent, Stony Dull percus­sion, Reduced chest expansion, Medias­tinal Shift if large

Pleurisy

- Inflam­mation of the pleura
S&S Sharp, Stabbing, well localised pain. Worse on inspir­ati­on/­cou­ghing
Causes: Pneunomia, PE, Chest injuries, Pneumo­thorax, Tumours of the lung, Inflam­mation associated with some forms of arthritis

Pneumonia

S&S: Cough, Sputum (can contain blood), SOB, Pleuritic Chest Pain, Weakness, Malaise, Myalgia, Fever, Breathless at rest, Chest expansion reduced on affected side, Percussion is dull over affected lobe, Auscul­tation - Crackles, bronchial breathing, pleural friction rub (heard more on expira­tion)
Bronchial Breathing - Harsher sound. Gap between inspir­ation + expira­tion.

Pulmonary Embolus

S&S: Pleuritic chest pain, Sudden onset SOB, Cough + Haemop­tysis, Tachyc­ardia, Increased breathing rate, Signs of DVT, Hypote­nsion, Pleural Rub, S3,S4 heart sounds
Virchow's Triad: Stasis of blood, Increased coagua­bility of blood (smoking, OCP, Cancer), Blood vessel abnorm­ality (previous DVT/Su­rgery to veins
Invest­iga­tions: Leg US (DVT), V/Q scan, CTPA, D-Dimer
Mangement: Refer to GP for antico­agu­lat­ion­/pr­oph­ylaxis

Perica­rditis

- Inflam­mation of the perica­rdium
S&S Patient complains of retro/left of sternum pain
Constant Sharp/­heavy and acting radiating into the axilla­/left arm
Fever and malaise present
Aggravated by deep breathing, coughing and lying down
Relieved by sitting forward

Rib f#

- Compre­ssion injury in the young. In the elderly it is caused by coughi­ng/­man­ipu­lation
S&S
Tenderness + swelling
Local spasm
Pain on respir­atory movements
Percus­sio­n/v­ibr­ation & Rib cage compre­ssion may be aggrav­ating
Manage­ment: Haemot­horax and pneumo­thorax are compli­cations - chest exam + chest x-ray
refer to GP/A&E

Mangement

- Refer if progre­ssive neurol­ogical sympto­ms/­mye­lopathy signs
- Soft tissue therapies and modalies
- Relaxation Techniques
- PIR

Disc Herniation

- Most occur below T9 (T11-T12) , due to increase in stresss of the region + changes in facet orient­ation
- Back pain + radicular pain - may refer to chest wall or abdomen unilat­era­lly­/bi­lat­erally
- Aggravated by bending forward, coughing, sneezing, straining
- +ve Beevor's sign + absent abdominal reflexes
- Look for signs of spinal compre­ssion; LL Ataxia, Bladder incont­inence , UMNL

Management

Mobili­sat­ion­/ac­tivator
Heat
Medication (analg­esics, NSAIDs)
Trigger point pressure relief
Ultrasound to the tender points
Encourage Abdominal breathing

DDx

MI
Muscle Strain, SC joint injury
Rib Fracture
Rib Sublux­ation
Fibrom­yalgia
GI Reflux
Anxiety
Lung Cancer

Clinical Findings

- Vital signs WNL
- Palpation: Palpation of joint increases pain, swelling uncommon unless Tietze's syndrome, no warmth­/re­dness
- Tx ROM limited - costos­ternal pain
- Crepitus not usually felt - consider f#

Costro­cho­ndritis

- Anterior chest wall pain, radiating into back, abdomen
- Unilateral + sharp in nature
- Exacer­bated by breathing, physical activity
- Caused by exercise or URTI

Differ­ences between MI and Tx

In the elderly

Consider: MI, Angina, dissecting aneurysm, ruptured aorta, Herpes, rib fracture, malign­ancy, pleurisy, pulmonary embolus and GI reflux
Other: Malignancy (multiple myeloma, lung, prostrate) , osteop­orosis, vertebral pathol­ogical f#, PMR, Paget's, IHD, Penetr­ating peptic ulcer, oesoph­ageal disorders, biliary disorders

In Children

- Can be Psycho­gen­ic/­unknown (most cases)
- Mean age for chest pain = 12 yo
- Usually MSK (strained pec, should­er/back muscles after exercise), cough induced pain, costoc­hon­drtis, asthma
- <12 yos consider cardio­res­pir­atory causes - cough, asthma, pneumonia, heart disease
- Consider tuberc­ulosis, Discitis, osteom­yel­itis, osteoid osteoma, osteos­arcoma for Tx back pain (rare)

Further invest­iga­tions

X-ray
Bone scan/MRI if X-ray normal
FBC, ESR, CRP

Exam

- Genera­lised kyphosis - common in elderly, scheue­rmanns in younger patients
- Scoliosis = more prominent on forward flexion
- Palpate: SPs, Facets, TVPs, Costot­ran­sverse junctions, posterior rib curve, surrou­nding muscle­s/f­ascia

Tx spine Hx

Aggrav­ation + relief on trunk rotation ( Aggravated by rotating to one side and relief by rotating opposite side)
Aggrav­ation of pain by coughing, sneezing or deep inspir­ation - sharp, catching pain = costov­ert­ebral joint
Key Hx Questions:
Back Injury? Did you lift something heavy?
Fall onto your chest/­back?
Pain wake you at night?
Low back pain/neck pain?
Pain come on after walkin­g/s­tre­nuous effort?
Pain come on after eating­/soon after going to bed at night?
Rashes?
Fever/­sweats?
Taking medica­tions?
What happens when you take a deep breath, cough or sneezing?

Red Flags

Fever accomp­anying chest pain - pulmonary infections
Abdomi­nal­/flank pain = acute pyelon­eph­ritis and cholec­ystitis
Unexpl­ained weight loss/f­atigue, >50 yos, pain at rest, night pain, failure to improve with treatment = Malignancy
Abdominal pain that comes and goes + Tx spinal pain = biliar­y/renal colic
Shortness of breath, cough, abdominal symptoms, chest heaviness, movement /change of posture not related to pain = cardiac and visceral disorders
Unrele­nting pain with NO relieving factors
Fracture - minor trauma = osteop­orosis