Chest Pain (Full Version)

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FLAOrthoPT -> Chest Pain (February 13, 2006 4:56:00 PM)

a 40 year old female comes in from an orthopedic surgeon referral with diagnosis of shoulder pain and impingement left arm. She complains of pain in her chest as well. Pain is reproduced with deep breathing and pushing over her sternum. Pain also with heavy repetitive activities overhead, and pain sometimes at night with rest.

What major common causes of chest pain would you rule out that are non musculo-skeletal, and which common diagnosis of musculoskeletal dysfunctions can cause chest pain. Just getting your noggins working...



Dr.Wagner -> Re: Chest Pain (February 14, 2006 2:34:00 AM)

When concerned with anyone regarding chest pain, stratification is necessary.
Family History of CAD
Pt History of CAD
Age/gender/race
Diabetes
Smoking
Obesity
HTN
Hyper Cholesterolemia/lipidemia
are most important
Then Stratify based upon description of discomfort, provocation, and alleviating factors.

Now this person likely has been ruled out based upon her referral to Orthopedics. So this is a case that is pretty far down the chain.

As far as Emergent and Fatal causes of chest pain there are 6 to review
1. MI
2. Unstable Angina
3. Pulmonary Embolism
4. Esophogeal Rupture
5. Aortic Dissection
6. Tension Pneumothorax

In this case, several musculoskeletal causes may be the cause...the first I would consider is a rib dysfunction.

As far as "medically complex" issues, most have been covered.
I can get more detailed if so desired.

Thanks



FLAOrthoPT -> Re: Chest Pain (February 14, 2006 2:55:00 AM)

what about lupus? what about herpes zoster? sure...keep going...just because they saw an ortho for 3 minutes you assume they have been ruled out of having anything serious? wow are you idealistic...



Dr.Wagner -> Re: Chest Pain (February 14, 2006 4:19:00 AM)

I am assuming you are asking a question, not a statement.

Well, the idea with differential diagnosis is to systematically attempt to change your thinking or align your thinking based upon physical exam and historical factors.
With the history coming first, a large amount of your differential may be focused...then the physical exam narrows the search.
Diagnostic testing narrows even more.

Now, as an Emergency Physician I don't think happy thoughts and the classic concerns of chest pain are those listed above (those are emergent causes).

Chest pain itself has MANY MANY MANY causes...but common things are common.

Lets look at Zoster, well historical factors such as "have you had shingles before" or a recent history of vessicular disease of the skin would narrow the cause. Then the physical exam narrows further. Post herpetic neuralgia is narrowed further by history.

Lets look at Lupus, well not terribly common, and historical factors should help. No distinct entities on the exam (minus any butterfly rash) and diagnostic tests become the priority.
Too many chronic pain syndromes look exactly like lupus, and of course lupus is stratified from minor to severe.


Historical factors are KEY with chest pain...then systematically ruled out with diagnostics. If I have a 50 year old diabetic smoker with chest pain on exertion...what is concerning? Angina.
What do you do?
Stress test.
If I have a 50 year old non smoker, with no family or patient history of CAD, diabetes or HTN, chest wall pain with movement, deep breaths and pressure over the sternum that may be 'waxing and waning' over days (never quite going away) one would likely rule out cardiac disease and pursue other things.
Medical vs. musculoskeletal. With likely a musculoskeletal cause.

Boy oh boy this could REALLY go on and on.

History is always the most important. It is interesting, the Fathers of Medicine in the Middle East would state that one need not even perform an exam, but the entire pathology could be diagnosed based upon history alone.
Now, while I and Osler may not agree completely, it makes a good point.

Hope that helps, perhaps I will post a case.



FLAOrthoPT -> Re: Chest Pain (February 14, 2006 8:02:00 AM)

no it helps, I have a case to post if need be. Just amazing when you really think about all the musculo-skeletal causes of chest pain, laxity of SC, rib strain, chondritis, pec strain, nerve entrap, thoracic herniation, etc, etc...and then you throw in all the GI: GERD, gall bladder, etc, and throw in the major cardiac issues, the pulm issues, the systemic diseases herpes and lupus, and it is like, no wonder why the ortho surgeon misses the non musculo skeletal cause and refers into you for shoulder impingement...just wanted those without a medical degree to do some thinking, but I guess you made it easy for them, next time I will say that you cannot comment until a day or 2 later-
Ben



Dr.Wagner -> Re: Chest Pain (February 14, 2006 9:07:00 AM)

I am sorry...I thought you had a question. My fault.
I love answering questions so I just go and go and go and go...



connie.pt -> Re: Chest Pain (February 14, 2006 2:56:00 PM)

I had a pt. referred to PT with the diagnosis on the Rx of "chest pain" from a family doctor. It was a very interesting case for me. Here's the history as I remember it:
Male about 40 years old, non-smoker but wife smoked.
Worked at a car company at the end of the line, where they drove out the finished product (a lot of exhaust).
About six months ago, started having seizures, denies having seizures before this.
About the same time, started having this chest pain.
No other musculoskeletal complaints, other than he noticed that his left arm would go numb about the same time, or just before the chest pain started.
Has also passed out a few times in this period for unknown reasons.
These things would happen at work or just sitting watching TV.
Diagnostic testing was negative, except for "something going on with the blood vessels in the back of my neck."

He had a positive vertebral artery test: the position provoked the chest pain and numbness, as well as pupil dilation/constriction, nystagmus, and voice hoarseness. I sent him back to the doctor, who sent him to vascular.

It was a very exciting case for me, especially because I had just graduated 6 months before this.



Dr.Wagner -> Re: Chest Pain (February 15, 2006 3:28:00 AM)

Why would you do a vertebral artery test if you knew "something was going on with the vessels in his neck"?

What if he became syncopal or worse?

It is a provacative test, if you know there is pathology, why provoke a potentially dangerous situation?

Holy CRAP you got exceedingly lucky this patient didn't have major issues during or after the test.


I would imagine the primary contra-indication to this test is known pathology of cervical vessels etc. If not, it should be!



SJBird55 -> Re: Chest Pain (February 15, 2006 4:01:00 AM)

If you read about the vertebral artery test, it isn't a good test or a gold standard test. Technically, the test doesn't really tell us anything. It's one of those tests we hold onto because we were taught it, but it has terrible sensitivity and specificity.



connie.pt -> Re: Chest Pain (February 15, 2006 7:19:00 AM)

Dr. Wagner,
The test was performed in supine, so if there was syncope it is less risky.
I had him move actively into rotation in a very small ROM, about 20 degrees without extension. As soon as nystagmus was detected, I had him return to neutral. Then I declined the head of the table about 10-15 degrees, which produced the same signs. Then he rotated his head slightly again in this position, which provoked his c/o.
The objective of my testing was to find out what may be causing the s/s. I did that in the safest possible way. Certainly putting him at end range of extension and rotation would have been dangerous. The end-range position was less than an emphatic shaking of your head would be. (Probably what you did when you read my post.)

I gave him a towel wrapped around his neck as a collar & told him to avoid turning his head.

SJ, the reliability and high false-positive rates are of concern from a research standpoint. From a clinical standpoint, it is still the best test we have without further diagnostic tests to determine if the vertebral artery may be comprimised.
As Childs, et al (JOSPT 2005) and Theil & Rix (Manual Therapy 2005) point out, the VA test may not give us any useful additional information in the decision-making of clinicians on whether or not manipulation may injure the VA. They also present that evidence of VA comprimise is a reason for referral.

There is evidence that cervical rotation can obscure the blood flow of the VA significantly enough to produce a stroke, ie a bowhunter's stroke.

There is also evidence that the position of the VA test significantly reduces blood flow in healthy individuals. (Mitchell, et al. Manual Therapy 2005; Nov 9(4) 220-7). If this test reduces blood flow in healthy individuals, those with vascular comprimise will most likely have an even more significant reduction of blood flow through the VA.

As far as I'm concerned as a clinician (vs a researcher), for those people who have S/S of VBI, it's the best test we have.



Dr.Wagner -> Re: Chest Pain (February 15, 2006 4:19:00 PM)

I think you are a sincere person who cares about her patient.
But I think you made a terrible mistake.

If a patient tells you "they said there may be something wrong with the vessels in my neck"...STOP. DO NOT PASS GO.

The problem with the test is that it is provacative. It is like telling a patient that is hypoxic to "hold their breath...let's just see how hypoxic you are".

Because of the LOW sensitivity and certainly awful specificity of the test, you could have PROVOKED a hypoxic event or worse...disloged a thrombus or plaque. You knew there was a problem, why would you pursue any further, especially if you were pursuing with a poorly specific test. It could NOT have told you anything more than you already knew "he had a problem with the vessels in his neck".

I think you had good intentions. Just don't do that again. Trust me.

The best test is an angiogram, NOT the manual VBI test. The second best is an MRA. The third is a CT with contrast...etc If you SUSPECT danger, DON'T GO LOOKING FOR IT!



connie.pt -> Re: Chest Pain (February 16, 2006 1:35:00 AM)

That's one of the best things about this forum; it helps me see things from other's point of view. I am chastened.



Dr.Wagner -> Re: Chest Pain (February 16, 2006 2:53:00 AM)

I hope people start reading the journal review I posted.



Randy Dixon -> Re: Chest Pain (February 18, 2006 2:39:00 PM)

I just want to give a pat on the back to Connie for presenting a hard case, and then taking the feedback like a professional.



nari -> Re: Chest Pain (February 18, 2006 3:21:00 PM)

If the VAT is unreliable, insensitive and potentially risky, and it certainly is...why do it at all? Ever? If one is going to manipulate, are there any other ways of determining VA patency? History can tell us a lot; what happens when the pt is hanging out clothes on a line (classic, if the pt is short),looking in tall cupboards for things, sitting at the bar looking at TV and chatting to people on either side and so on.
History / narrative can tell us a heck of a lot if we ask the right questions.

Nari



Dr.Wagner -> Re: Chest Pain (February 19, 2006 3:03:00 PM)

The job of the VAT is to screen potential patient (yet is it a good screen at all). But this is a patient who KNEW disease was present...screening had ALREADY taken place. What was to be gained via a provacative test? Nothing.
And yes, it is difficult to read criticism from a blank face such as mine. In person, I am VERY easy to get along with, and pretty easy to understand. I am very glad she did not get defensive.



chiroortho -> Re: Chest Pain (February 19, 2006 5:39:00 PM)

So glad that we have a discussion about the validity of VA patency tests. As for me, the history is my best test. A bruit is kind of like putting scallions on a bowl of hot and sour soup - nice but totally unnecessary.

History, history, history. Need I repeat my chiropractic self?



Jeep -> Re: Chest Pain (February 20, 2006 2:30:00 AM)

[QUOTE]The best test is an angiogram, NOT the manual VBI test. The second best is an MRA. The third is a CT with contrast...etc [/QUOTE]Would you order the tests in that order?
If I suspected VBI, I would order an MRA. Do think otherwise?



Dr.Wagner -> Re: Chest Pain (February 20, 2006 4:28:00 AM)

Absolutely Greg...yes yes yes.

This patient would need a referral of course to either a vascular surgeon, general surgeon with experience in vascular disorders, or neurosurgeon (probably not). I order a limited amount of these tests (a handful in a year). Usually this is in conjunction with someone who can actually "do something" with the results. I order the test, with the results sent to them. Of course this is at least a 5 thousand dollar test. Ordering said test should never be cavalier.

The textbook answer is "angiography" via interventional radiology. If that is available.
MRA is a nice substitute.

Usually a MRA is easier to schedule and to order. Not every facility has an interventional radiologist.



Jeep -> Re: Chest Pain (February 20, 2006 4:50:00 AM)

Could you please list pros and cons of each?

Thanks



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