Chest pains

 

Chest painsIt is an often revealing manifestation of cardiovascular disease, but it can also translate pulmonary, digestive, musculoskeletal affections.

CLINIC:

The interrogation:

– Clarifies the patient’s cardiovascular and pulmonary history, medications.

– Heart pain is typically described by the patient with a characteristic hand gesture (open hands or tight fist), while pleural pain will be described as a side point.

But it is necessary to make specify to the patient the type of the pain   :

 its exact seat and its irradiations;

 its characters: constriction, burn, weight …;

 its intensity and duration;

 its triggering factors, its schedule and its sedative factors.

Tolerance of pain will be appreciated by objective criteria:

 blood pressure;

 heart rate;

 the existence of cyanosis, sweating;

 the state of consciousness and the anxiety generated.

The clinical examination is oriented on the cardiac and respiratory sphere, but must be complete.

ADDITIONAL EXAMENS:

Two are essential: the electrocardiogram and the chest x-ray   which alone allows the majority of diagnoses.

The other examinations are directed by the clinic: dosage of D-dimer, ultrasound of the lower limbs, assay of cardiac enzymes, gastric fibroscopy …

TECHNOLOGY:

Conditions leading to emergency hospitalization:

INFARCTUS OF MYOCARDIA:

The pain is typically constrictive, retro-sternal, radiating to the arms and lower jaw.

Intense, prolonged pain and resistant to trinitrine. You should know that the first ECG performed in   urgency may be little changed. The characteristics of the pain, the anxiety it engenders must be sufficient to alert.

ANGINA:

Either effort, or first decubitus, or spontaneous, it gives a pain almost identical but gives in less than a minute after the administration of sublingual trinitrine. In effort angina, the pain stops when the effort stops.

The features of coronary artery pain are very accurate and very reliable for diagnosis.

PULMONARY EMBOLIA:

The pain is sudden, in principle latero-thoracic, accentuated by coughing or breathing. Here the clinic is less profitable,  attention should be paid to signs of examination, tachycardia, dyspnea, signs of right heart failure, phlebitis of the lower limbs (venous doppler).

We must focus on the patient’s anxiety, the evocative circumstances (postoperative, bed rest, thromboembolic antecedents …).

PNEUMOTHORAX:

Brutal chest pain, no fever, dyspnea and dry cough. The examination is characteristic in a complete pneumothorax: hypersonority, abolition of vesicular murmur and vocal vibrations.

For a partial pneumothorax, only the X-ray will be talking.

AORTIC ISSECTION:

She is often misleading. Typically the pain is violent, prolonged to type of tearing or stabbing, retrosternal with dorsal irradiation. In fact, be wary of any median pain with upward radiation, sometimes even in the nose … The examination will look for a breath of aortic insufficiency, the decrease or the abolition of a pulse, a tension asymmetry in the upper limbs, a hypertension .

PANCREATITIS:

The pain radiates in the back, there is often a paralytic ileus (abdominal distension, nausea …), fever, tachycardia, a small epigastric defense.

Conditions not leading to emergency hospitalization:

PERICARDITIS:

Often viral, it determines a medico-thoracic pain; the frequent occurrence of friction, ECG and echocardiography allow diagnosis. An anti-inflammatory treatment is usual, most often without hospitalization. Only the occurrence of tamponade would require urgent hospitalization.

PLEUROPULMONARY PAIN ORIGIN:

Pneumopathies and bronchitis can cause chest pain, but it is always necessary to mention first and eliminate a pulmonary embolism in these cases.

DIGESTIVE PAIN ORIGIN:

– Gastroesophageal reflux: retrosternal burns with upward irradiation, favored by anteflection.

– Gastroduodenal ulcer: pain of characteristic schedule, calmed by food intake.

PARIETAL PAIN ORIGIN:

They are localized pains, aroused by pressure, triggered by certain movements.

Origin articular (chondro-costal joints) or muscular (inter-costal muscles), bone (odds, sternum).

NEUROLOGICAL PAIN ORIGIN:

Affections above C6:

– Herpes zoster: superficial burn pain on the path of one or more dermatomes;

– Intercostal neuralgia;

– Rarely spinal pathology.

TREATMENT:

It depends on the etiological diagnosis, it is always necessary to calm a chest pain possibly with morphine.

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