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 |
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