Thursday, 29 May 2008
Below is a set of radiographs of a patient who presented with increasing cough, dyspnoea and fever.
The patient had long-term untreated diabetes mellitus and there was a history of chronic, heavy smoking.
On examination, dental hygiene was poor and the physical examination of the chest revealed no abnormalities to percussion or auscaultation. Abdominal examination was normal.
The patient had an ischaemic ulcer present on the right lower later limb.
1) What is the diagnosis from the history, physical examination and Xray findings?
2) List the likely cause(s)
3) What other tests would you do?
4) What is the current evidence based treatment of such a condition?
Posted by ブランチ先生 at 7:51 am
Monday, 26 May 2008
Sorry for almost a week of absence from this blog. I hope this entry makes up for the short hiatus.
Today I would like to discuss about chest pain.
Chest pain is one of those things that is either something innocuous or on the other hand may be extremely serious. It is up to us as doctors to decipher the 'chaff from the wheat', or in other words, determine whether we need to do lots of tests and treatments or not.
Chest pain is a big topic in itself and too much to go into in detail in this blog. However, when we ask about chest pain we should not just rely on the patient saying that they just have chest pain and we as physicians should not just leave it at that. Chest pain needs thorough investigation through history, examination, radiological, laboratory and electrocardiographic modalities.
If we simply accept the phrase 'chest pain' and do nothing more, then we are short changing the patient and maybe missing a life threatening diagnosis.
So, when we ask about chest pain, we need to know what type of pain.
Cardiac pain is classically heavy / pressing / squeezing -- like someone standing on your chest. It is usually the worst pain ever and patients may say it is 10/10 on the pain scale. The location is usually central chest and may radiate through to the back or into the abdomen especially if it is an inferior MI. Patients may mention or may have to be asked if the pain radiates to the jaw, neck or either arm or whether there is numbness in the fingers. Associated symptoms of nausea, vomiting, breathlessness and sweating are other classic features of ischaemic chest pain.
Other cardiac causes of chest pain can be aortic dissection which can present with very similar symptoms as patients with acute coronary syndrome. However, patients can develop tearing interscapular pain (between the shoulder blades), cardiovascular collapse from tamponade, limb weakness from arterial occlusion as the dissection occludes the vessels derived from the arch of the aorta. If the dissection moves distally, abdominal organ ischaemia can occur resulting in pain, renal failure and ischaemic bowel. Hence, a patient who starts off with chest pain that then migrates to neck / shoulder blades, lower back and abdomen should be suspected of a dissected aorta until proven otherwise.
Sometimes, fast dysrhythmias can result in chest pain because of rate-related ischaemia and can be due to non-sustained VT, Atrial fibrillation-flutter, Wolff-Parkinson-White syndrome etc. Hence, asking the patient whether they have a fast, regular or irregular pulse may give you a clue to the cause before putting a hand upon the patient.
Another cause of chest pain is pericarditis which is usually infective although non-infective causes are also well known e.g. connective tissue disease, post-AMI, Dressler Syndrome. Such acute pericarditic symptoms include sharp localised pain over the area of the heart, worse on lying flat and better when sitting forwards. Patients may also develop tamponade if severe and especially if taking anti-coagulants or if they are mistakenly given thrombolysis for suspected AMI. However, pericarditis can masquerade as an AMI and hence, it is not always possible to decipher the two conditions without further investigations and intervention.
Pulmonary Embolism is something that should never be forgotten but is not usually high up on physicians differential diagnosis lists in Japan. It should be. Although I have indeed seen far fewer DVTs and pulmonary emboli in patients in Japan, I have nevertheless seen such cases. Symptoms include sudden or gradual onset of dyspnoea, chest pain- typically pleuritic, cough, haemoptysis, palpitations, collapse etc. Sometimes patients will have a classically swollen lower limb containing a DVT although I have found this to be the exception rather than the rule. Remember that patients with pneumonia, cancer, UTI, bed ridden etc can get DVT-PE and just thinking of a single pathology can catch you out. For example, a patient with a pneumonia who remains hypoxic and who may also, for example, have persistent AF despite resolving pneumonic changes should be considered to have a PE until proven otherwise.
Chest pain can also be from lung conditions such as pneumonia, pleurisy and malignancy where the pathology involves the parietal pleural which is innervated by peripheral intercostal nerves and the phrenic nerve of the diaphragm. Hence, such pleuritic pain is a lancinating pain (stabbing) when the patient breathes or moves/coughs etc. This may limit the patient taking a deep breath. Patients may also experience shoulder tip pain on one side and may signify inflammation of the diaphragm with radiated pain via the phrenic nerve especially around the area of the central tendon of the diaphragm. Inflammation on the other side of the diaphragm e.g. peri-hepatitis, abscess etc can also result in shoulder tip pain.
Pneumothorax and pneumomediastium can result in sudden onset of chest pain. These may produce pain during respiration. The latter may only be considered if there is trauma or gastro-oesophageal symptoms (?? rupture of the oesophagus) and may only then be considered if there is crepitus in the supra-clavicular fossae or air is seen tracking up the mediastinum on chest X-ray.
The ribs of the thorax may also give rise to pain especially if there have been fractures or if there are metastases and asking about bone pain or symptoms of hypercalcaemia are also worthwhile.
Of course, a common and innocuous cause of chest pain is muscle damage from heavy lifting and this can cause the patient anxiety.
Back pathology may also cause central chest pain !! Vertebral collapse, fractures, osteoarthritis etc, can irritate the intercostal nerves and produce a lacinating pain over the distribution of these nerves and is worse when the patient moves. This kind of pathology should always be investigated. Many years ago I saw a patient with typical unstable angina who also had pain lacinating round his chest wall who on more detailed examination, had a tender spine. He had two pathologies causing his chest pain!
There are several serious causes of "chest pain" that originate in the abdomen too.
As mentioned oesophageal rupture is one. Others include pancreatitis, gastric ulceration, cholecystitis, cholangitis etc.
Because the nerve supply to the abdominal viscuses is from the slower unmyelinated nerves, there is poor localisation of pain unless there is inflammation of the overlying parietal peritoneum. Hence, patients with, for example, pancreatitis can experience lower chest pain / upper epigastric pain and may have some ease of discomfort when sitting forwards.
Patients with gastric / duodenal ulceration may experience epigastric pain and may also have GERD symptoms such as reflux, retrosternal burning especially when lying flat, flatulence, bitter taste in the back of the mouth and lots of saliva (waterbrash). Patients may not offer up such symptoms unless asked !
Cholecystitis / cholangitis typically gives right hypochondrial or epigastric pain and this can radiate the infrascapular area on the right side. Patients can have fever and jaundice too. However, the patient may define the pain as chest or even back pain and hence, such a diagnosis should always be borne in mind.
Of course, there are several other causes of chest pain that are of no long term consequence. These include the Tietze's "costochondritis" and Bornholme's disease-- coxsackie infection. Elderly patients should also be asked if they have ever had Shingles (VZV dermatomal rash) over the area of the chest pain as post-herpetic neuralgia is occasionally the cause. The give away sign for the diagnosis is the unilateral post-infective scarring of the skin.
Hence, when taking a history about chest pain, it is simply not accepting what the patient says to you. You must ask more detail!!
Thus, a typical set of questions would include:
- What type of chest pain is it? Can you describe it?
- Is it squeezing, sharp, dull, shooting, stabbing or burning?
- Is the pain sqeezing or heavy ? Does it feel like an elephant standing on your chest?
- Is it the worst pain you ever experienced? If 10 is the worst pain ever and 1 is almost no pain, where would you place your pain on this scale?
- Is the pain moving anywhere else, for example, into your neck, jaw or arms?
- Are you getting any tingling in your fingers?
- How long does the pain last? Is it continuous or coming on from time to time (intermittent)?
- Does the pain build up to a crescendo or does it stay the same?
- Is there anything that makes it better or worse?
- What happens if you walk? Does the pain get worse too?
- Is there any associated nausea, vomiting, sweating or breathlessness?
- If you use a nitro-spray / tablet, does the pain get better? (This can relieve cardiac pain AND oesophageal spasm so please don't get caught out!) How long does it take for there to be easing of the pain? Minutes?
- Is you heart ever racing? Do you get chest pain at the same time? Is the racing regular or irregular? If you change your body position, such as squatting or bending over, does the racing stop and chest pain stop?
- Do you drink lots of coffee or alcohol?
- Any history of problem with your thyroid gland in your neck? Any sweatiness? Any tremor of your hands? Increased appetite and weight loss? How are your eyes? Anyone said they look larger recently?
- Does the pain go through to your back? Is it severe or tearing?
- Have you noticed any arm or leg weakness or new back or stomach (abdominal) pain?
- Are you feeling breathless?
- When you breathe, cough or sneeze, does the pain get worse?
- Does the pain get better on sitting forwards or worse on lying flat?
- If you use pain killers, does the pain become less?
- Any recent fever, cough, cold or sniffles? (URTI symptoms--usually viral origin)
PULMONARY EMBOLISM / PLEURISY / PNEUMONIA QUESTIONS
- Do you have sharp chest pain, fever, cough, phlegm, bloody phlegm, palpitations or sudden or gradual onset of breathlessness?
- Any shoulder tip pain?
- Any history of long haul flights, long car journeys or immobility from illness?
- Do you take any medications such as oestrogens? Have you ever had cancer? Do you smoke? Any exposure to asbestos?
GASTRIC / OESOPHAGEAL QUESTIONS
- When you eat or drink, does the pain get better or worse?
- Do you get symptoms of chest burning, flatulence, a bitter taste in your mouth or lots of saliva, especially when lying flat at night? Does milk or antacids make it better?
- Have you noticed a change in the colour of your stool? Is it black like tar? Is it foul smelling? Do you feel dizzy on standing? Do you get breathless or have palpitations?
- Are you under lots of stress? Do you take aspirin or pain killers or steroids? Have you ever had an ulcer?
PANCREATIC / LIVER / GALLBLADDER QUESTIONS
- Have you noticed any change in the colour of your eyes, skin or urine? Have they turned yellow / dark brown? Does the chest pain get better when sitting forwards? Have you been vomiting?
- Does the chest pain come on several hours after eating? Is it mainly when you eat fatty foods? Do you ever get pain under the right shoulder blade or shoulder tip pain ? (sub-phrenic abscess)
- Do you get shivering or shaking with a fever? (may signify gram negative septicaemia e.g. ascending cholangitis, sub-phrenic abscess)
- Do your bones hurt? If you press on your own chest, do the bones ever hurt? Do you get pain worse at night? Does it ever keep you awake? Have you had any recent injury to your chest? Do you take steroids? Any recent weight loss, night sweats or fever?
- Do you have any back pain? Worse when coughing or sneezing? Is this ever associated with the chest pain?
- Do you get pain in your muscles or chest when you lift something heavy? Have you done any recent heavy lifting at all?
SKIN AND SOFT TISSUE RELATED QUESTIONS FOR CHEST PAIN
- Have you noticed any recent skin complaints such as a rash? Have you ever had shingles in the area of the chest pain?
- Have you noticed any breast pain or recent lumps that are of concern to you (especially female patients).
NON-SPECIFIC INFECTION RELATED QUESTIONS
- Any recent foreign travel?
- Any recent contact with another sick person?
- Any recent common cold symptoms?
CONNECTIVE TISSUE RELATED QUESTIONS
- Any pain or swelling of any joints in your body?
- Do they get stiffness? How long for? More or less than one hour in the mornings?
- Anyone in the family with rheumatoid arthritis or other types of immune related diseases?
QUESTIONS FOR INVESTIGATING HYPERCALCAEMIA
- Are you thirsty or passing lots of urine ? (nephrogenic diabetes insipidus)
- Do you get confused or have problems with concentration?
- Do you get constipation or abdominal pains?
- Have you had any recent kidney stones? Have you ever passed a stone in your water?
- Do you get pains in your bones?
- Have you had a recent bone fracture?
The above can be remembered as the 'Bones, Stones, Abdominal Groans and Psychic Moans'.
As you can see from the above, asking about chest pain is not just a five minute chat!! It takes time but must be done if you are to find the true pathology.
Of course, the physical examination may help you a lot. Pressing on the chest may elicit bone pain, percussion may reveal hyper-resonance of a pneumothorax or reduced percussion sound of a pneumonia. Crepitus in the neck may alert you to the pneumomediastinum, or the supraclavicular lymph nodes and unilateral dorsal muscles wasting of the hand may alert you to the Pancoast tumour in the apex of the lung. Of course, the aortic diastolic murmur may be attributed to acute aortic regurgitation and reduced valvular sounds from the ensuing tamponade of a dissection etc....
Therefore, putting together the detailed history with the physical examination is necessary to provide a clearer idea of what the likely underlying process is. Without these two essential and complementary elements, the doctor will have no way to understand the problem and follow on tests will be unfocused and may miss the problem.
Only with the detailed history and physical will one have an idea of what to investigate, and remember from the above non-exhaustive list, there are many potential causes to investigate.
However, a patient with chest pain should have the following basic and cheap examinations despite the underlying cause to exclude serious pathology:
- Chest roentogen (Chest X-ray) --ERECT TYPE IS BETTER to look for perforation, pneumonia, pneumothorax, widened mediastinum, etc
- Electrocardiogram (ECG) e.g. AMI, pericarditis, AF
- Cardiac enzymes, most particularly a Troponin T at a minimum of 6-12 hours after the onset of chest pain (positive in AMI, PE, Myopericarditis, CPR-Trauma, PCI)
- D-Dimer (positive in DVT-PE; good negative predictive value)
- Amylase and liver function test (Amylase raised in Pancreatitis, cholecystitis, perforation, dissection, DKA, Macroamylasaemia, etc )
- Complete blood count to look for signs of a raised white cell count and neutrophil left shift
- Temperature, pulse oximetry, respiratory rate and blood pressure measurement
- Corrected Calcium and ALP check in case of bone pathology.
There are many other basic tests that one could do but they would depend on the results of the above investigations e.g. cardiac echo if suspicious of aortic regurgitation, treadmill test. Modalities like CT, MRI should not be launched into without first assessing the underlying cause and determining whether it will give you the appropriate answer.
Of course, patients with non-specific chest pain can end up being over-examined on occasion. However, ruling out serious pathology is necessary.
Today's discussion is just the tip of the iceberg when it comes to discussing symptoms and how to ask the right questions. My advice to you is to think of the potential serious causes of pathology when thinking in terms of the presenting symptoms. Then once considered, ask yourself how these illnesses present as symptoms and ask those same questions to the patient. Without a deep background knowledge of how diseases present themselves, then one becomes reliant on machines making the diagnosis rather than the doctor.
Machines are not always right.
Posted by ブランチ先生 at 1:18 am