bol u grud uvod
-
Upload
micija-cucu -
Category
Documents
-
view
232 -
download
0
Transcript of bol u grud uvod
-
7/27/2019 bol u grud uvod
1/17
Assessment of chest painOverview
Summary
Aetiology
Emergencies
Urgent considerations
DiagnosisStep-by-step
Differential diagnosis
Guidelines
Resources
References
Images
Patient leaflets
Credits
Email
Print
Feedback
ShareAdd to Portfolio
Bookmark
Add notes
SummaryChest pain is a common chief complaint, accounting for 5% to 8% of all emergency department visits in the US
per year,[1] and is the presenting complaint in 1% to 2% of office-based visits.[2] In general practice in the UK,
the incidence of newly diagnosed chest pain is 15.5 per 1000 person-years.[3]
Chest pain may be caused by either benign or life-threatening aetiologies and is usually divided into cardiac and
non-cardiac causes. Acute coronary syndrome (ACS) encompasses unstable angina and MI. ACS affects only a
few of the patients presenting with chest pain, but excluding ACS is vital because of the mortality associated with
untreated MI. This monograph concentrates on the assessment of chest pain in the emergency setting.
Differential diagnosisSort by: common/uncommonorcategoryCommon
Acute coronary syndrome
Stable angina
Pulmonary embolism
Pneumonia
Viral pleuritis
GORD
Costochondritis
Anxiety or panic disorder
Uncommon
Pericarditis
http://bestpractice.bmj.com/best-practice/monograph/301/overview.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/aetiology.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/emergencies.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/emergencies/urgent-considerations.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/step-by-step.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/guidelines.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/patient-leaflets.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/credits.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/feedback/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/share/301/overview/summary.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Chest+pain+(Assessment+of)+-+Summary&dataValue=%2Fbest-practice%2Fmonograph%2F301.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-2http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-2http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-2http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/summary/by-category.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-1http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-2http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-8http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-11http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-13http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-18http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-20http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-3http://bestpractice.bmj.com/best-practice/monograph/301/overview.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/aetiology.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/emergencies.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/emergencies/urgent-considerations.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/step-by-step.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/guidelines.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/patient-leaflets.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/credits.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/feedback/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/share/301/overview/summary.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Chest+pain+(Assessment+of)+-+Summary&dataValue=%2Fbest-practice%2Fmonograph%2F301.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-1http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-2http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-3http://bestpractice.bmj.com/best-practice/monograph/301/overview/summary.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/overview/summary/by-category.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-1http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-2http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-8http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-11http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-13http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-18http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-20http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-3 -
7/27/2019 bol u grud uvod
2/17
Cardiac tamponade
Aortic dissection
Aortic stenosis
Mitral valve prolapse
Pneumothorax
Pulmonary hypertension
Peptic ulcer disease (PUD)
Oesophageal spasm
Acute cholecystitis
Pancreatitis
Herpes zoster
Gastritis
AetiologyThe common aetiologies of chest pain in the primary care setting aremusculoskeletal (36%), gastrointestinal (19%), stable angina (10.5%),unstable angina or MI (1.5%), other cardiac (3.8%), psychiatric (8%), andpulmonary (5%). In 16% of cases the cause is not established.[4]
Aetiologies of patients over 35 years of age, admitted to hospital from theemergency department with a chief complaint of non-traumatic chest painare:[5]
acute myocardial infarction (10.7%)
angina/coronary artery disease (22.5%)
atypical chest pain (29.4%)
aortic dissection (0.3%)
other cardiac causes, primarily CHF and atrial fibrillation, (13.8%)
pulmonary embolus (0.4%)
non-PE pulmonary causes, primarily bacterial pneumonia, (11.2%) but also spontaneous
pneumothoraces (0.6%)
abdominal causes (1.6%)
other (10.2%).
http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-4http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-5http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-6http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-10http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-12http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-14http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-15http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-16http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-17http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-19http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-628886http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-5http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-5http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-5http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-4http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-5http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-6http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-10http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-12http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-14http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-15http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-16http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-17http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-19http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-628886http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-4http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-5 -
7/27/2019 bol u grud uvod
3/17
Urgent considerationsSee Differential Diagnosis for more details
Acute chest pain warrants rapid clinical assessment, as underlying disease can be life-threatening. Continuous
monitoring of pulse, BP, and oxygen saturation is standard care. If the patient is in pain or breathless, or oxygen
saturation is
-
7/27/2019 bol u grud uvod
4/17
initiated in those patients with PE. D-dimer is helpful in excluding PE.[9] For patients who have a high suspicion
for PE, a transthoracic echocardiogram demonstrating right ventricular hypokinesis and paradoxical septal
motion may indicate acute right ventricular failure from a PE.[9] In patients with shock, systemic thrombolysis,
catheter-directed thrombolysis, or surgical embolectomy should be considered.
Cardiac tamponadeCardiac tamponade may occur suddenly as a result of trauma, aortic dissection, or gradual accumulation of fluid
in the pericardial space. Early recognition and appropriate drainage of pericardial fluid is vital. The condition can
present with muffled heart sounds, distended neck veins, and pulsus paradoxus. Diagnosis is made by
transthoracic echocardiography.
Red flags
Acute coronary syndrome
Pulmonary embolism
Pneumonia
Cardiac tamponade
Aortic dissection
Aortic stenosis
Mitral valve prolapse
Pneumothorax
Acute cholecystitis
Pancreatitis
Step-by-step diagnostic approachChest pain can be triaged into traumatic and atraumatic aetiologies. The evaluation of atraumatic chest pain
requires an algorithmic approach that first excludes acute myocardial ischaemia before working through the
various aetiologies of chest pain.
History
The character of chest pain should be determined, as this can help differentiate between cardiac, respiratory,
musculoskeletal, and other causes. The type, severity, location, and duration of pain; the presence of any
radiation; and exacerbating or relieving factors may be helpful in pointing towards a diagnosis. Clinical
presentation alone cannot reliably determine acute coronary syndrome (ACS).[10] [11] Past medical history and
specific cardiac risk factors such as known cardiac disease, raised cholesterol, hypertension, smoking, and
family history support a cardiac cause.[12] Cocaine use also makes cardiac ischaemia more likely.[13]A
detailed drug history should also be taken (e.g., use of NSAIDs may result in gastric aetiology).
Certain characteristics of chest pain can give clues to the origin.
Constricting pain may be due to cardiac ischaemia or oesophageal spasm.
http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-1http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-8http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-4http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-5http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-6http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-10http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-16http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-17http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-11http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-11http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-13http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-1http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-8http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-9http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-4http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-5http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-6http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-10http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-16http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html#expsec-17http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-10http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-11http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-12http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-13 -
7/27/2019 bol u grud uvod
5/17
Pain that lasts over 20 minutes and is dull, central, and crushing is likely to be caused by an MI.
Pain that radiates to the jaw or upper extremities suggests a cardiac cause.
Sharp pleuritic pain that catches on inspiration may originate from the pleura or pericardium and
suggests pneumonia, pulmonary embolus, or pericarditis.
A sudden substernal tearing pain that radiates towards the back is the classic presentation of aortic
dissection.
Precipitating and relieving factors can help distinguish between cardiac and gastrointestinal causes (e.g., GORD,
peptic ulcer disease, oesophageal spasm). Pain brought on by food, lying down, hot drinks, or alcohol, and
relieved by antacids suggests a gastrointestinal cause. Cardiac pain is more likely to be brought on by exercise
or emotion and is typically relieved with rest or nitrates. Abdominal pathology such as acute cholecystitis and
pancreatitis may also cause pain referred to the chest. Dyspnoea is an associated symptom in patients with
cardiac ischaemia, PE, pneumothorax, or pneumonia. Nausea, vomiting, and sweating may be seen in patientswith MI.
Physical examination
Physical examination can further narrow down the differential.
Abnormalities revealed in the cardiac examination include abnormalities in pulse or heart sounds (e.g., new
onset of aortic stenosis or worsening of existing murmur), hypo- or hypertension, and signs of heart failure.
Crepitations revealed by auscultation in one or both bases suggest pneumonia or heart failure. Reduced breath
sounds on one side can be caused by a pneumothorax, or focally due to a collapsed lobe.
Tenderness on palpation over the area of chest pain usually indicates a musculoskeletal cause, such as
costochondritis. However, many patients with MI also have chest wall pain on presentation.
A gastrointestinal origin of chest pain is associated with a normal cardiac and respiratory examination, unless
there is existing but stable comorbidity. An abnormal abdominal examination (tenderness, rebound, guarding)
make a gastrointestinal aetiology more likely.
Basic investigations
Basic observations such as temperature, BP, pulse, and respiratory rate should be monitored.
ECG is performed in most patients unless a non-cardiac diagnosis can be made with confidence (e.g.,
pneumothorax). The ECG should be done as soon as possible after presentation. ST changes such as ST
elevation or ST depression, QRS abnormalities, arrhythmias, or tachycardia or bradycardia are characteristic
findings in cardiac causes.View imageView imageView imageView image
http://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/1.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/2.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/4.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/5.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/1.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/2.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/4.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/5.html -
7/27/2019 bol u grud uvod
6/17
CXR can confirm respiratory disorders such as pneumothorax or pneumonia. Cardiac ischaemia is often
characterised by a normal CXR, but a CXR can provide clues to serious cardiac pathology, such as a widened
mediastinum in aortic dissection,View image or a large globular heart in cardiac tamponade.
Blood tests
Cardiac biomarkers (e.g., CK, CK-MB, troponin I and T) found in skeletal and cardiac muscle are raisedin many situations including MI, following a fall or seizure, myositis, hypothermia, or hypothyroidism. CK peaks
approximately 48 hours after the event. CK-MB can be requested if the source of the enzyme needs to be
determined. Troponins peak at 12 to 24 hours after the event and are more sensitive for cardiac damage.
Cardiac biomarkers should be ordered on presentation and at least every 6 to 8 hours after presentation.
An FBC should be ordered to screen for anaemia and evidence of infection.
A renal profile is useful as a baseline test.
Some of the differential diagnoses for chest pain can be excluded or confirmed after history, physical
examination, and basic investigations have been carried out. These include ST-elevation MI (STEMI),
pneumothorax, pneumonia, pericarditis, and costochondritis. The results of the second set of cardiac biomarkers
confirm the diagnosis of non-ST-elevation MI (NSTEMI).
Further investigations
Some differentials need further investigations to confirm the suspected diagnosis.
Coronary angiography is required urgently in patients with a STEMI and in patients with an NSTEMI who have
high-risk features such as ongoing chest pain and dynamic ECG changes.
Once ACS, ventricular arrhythmias, and haemodynamic instability are excluded, patients with chest pain that is
clinically considered to be ischaemic in origin should be stratified by their likelihood of having angina and risk for
MI.
1. Definite angina: patients with a pretest probability of having CAD of >90% should be directly referred for
coronary angiography.
2. Probable angina: patients with a 50% to 90% pretest probability of having CAD may be referred for
stress testing with imaging.
3. Possible angina: patients with a 10% to 50% pretest probability of having CAD should be referred for
either exercise stress testing (EST) or stress testing with imaging.
4. Non-anginal symptoms with a pretest probability of
-
7/27/2019 bol u grud uvod
7/17
Transthoracic echocardiography is a non-invasive way of assessing cardiac function. It is necessary if cardiac
tamponade is suspected and is helpful in confirming a diagnosis of pulmonary hypertension. For a diagnosis of
aortic dissection to be made, transoesophageal echocardiography is more useful. A CT chest is an alternative if
aortic dissection is suspected.
Depending on local availability, a V/Q scan, CT pulmonary angiogram, or pulmonary angiogram is necessary ifPE is suspected.View image
If a gastric diagnosis is the more likely cause for chest pain, then investigations such as
oesophagogastroduodenoscopy, oesophageal pH monitoring, oesophageal manometry, barium swallow,
and Helicobacter pyloribreath test can be considered. A therapeutic trial of proton-pump inhibitors can relieve
symptoms in patients with GORD.[14] Further blood tests such as liver profile, serum lipase, and ABG analysis
may be necessary if acute cholecystitis or acute pancreatitis is suspected. These diagnoses also require further
imaging such as abdominal ultrasound and abdominal CT (for acute pancreatitis).
http://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/6.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-14http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-14http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-14http://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/6.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-14 -
7/27/2019 bol u grud uvod
8/17
Chest pain assessment algorithm.
NSTEMI: non-ST-elevation MI; STEMI: ST-elevation MICreated by the BMJ Evidence Centre
Differential diagnosisSort by: common/uncommonorcategory
Commonhide allAcute coronary syndrome
see our comprehensive coverage of Overview of acute coronary syndromeHistory Exam 1st test
central chest pressure, squeezing, or
heaviness; radiation to jaw or upper
extremities; associated nausea, vomiting,
dyspnoea, dizziness, weakness; occurs at
rest or accelerating tempo (crescendo); risk
factors: smoking, age (men >45, women >55
examination may be normal;
jugular venous distention, S4
gallop, holosystolic murmur
(mitral regurgitation), bibasilar
rales; hypotensive, tachycardic,
bradycardic, or hypoxic depending
ECG: ST-elevation MI (STEMI):
segment elevation >1 mm in 2
anatomically contiguous leads o
left bundle-branch block; non-ST
elevation MI (NSTEMI) or unstab
http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis/by-category.htmlhttp://bestpractice.bmj.com/best-practice/monograph/152.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis/by-category.htmlhttp://bestpractice.bmj.com/best-practice/monograph/152.html -
7/27/2019 bol u grud uvod
9/17
years), positive FHx of premature CAD,
hypertension, hyperlipidaemia, diabetes,
stroke, or peripheral arterial disease[6] [7]
on severity of ischaemia[6] [7] angina: non-specific; ST-segme
depression or T-wave inversionM
CXR: normal or signs of heart fa
such as increased alveolar
markingsMore cardiac enzymes: elevated in S
and NSTEMI; not elevated in
unstable anginaMore
Stable angina
see our comprehensive coverage of Chronic stable angina
History Exam 1st test Other tests
known history of coronary artery disease; chest
discomfort on exertion; no change in intensity,
frequency, or duration; associated diaphoresis,
nausea/vomiting, or shortness of breath; risk
factors: smoking, age (men >45, women >55 years),
positive family history of premature CAD,
hypertension, hyperlipidaemia, diabetes, stroke, or
peripheral arterial disease[7]
no specific findings
for CAD, may have
abnormal pulses if
peripheral vascular
disease present
ECG: no acute changes;
may have evidence of
previous infarction, such
as Q waves
CXR: normal or
cardiomegaly
cardiac biomarkers: not
elevated
stre
slo
ele
pos
reg
ven
cor
arte
CT
ste
Pulmonary embolism
see our comprehensive coverage of Pulmonary embolism
History Exam 1st test O
sharp and pleuritic in nature; shortness of breath;
haemoptysis may occur if pulmonary infarction
develops; massive PE results in syncope; risk
factors: history of immobilisation, orthopaedic
procedures, oral contraceptive use, previous PE,
hypercoagulable states, or recent travel over long
distances;[28] unilateral swollen lower leg that isred and painful suggests DVT; use of the modified
Wells criteria can help to screen for risk factors and
clinical features suggesting high probability[29]
tachycardia, loud P2, right-
sided S4 gallop, jugular
venous distention, fever,
right ventricular lift;
massive PE may cause
hypotension[28]
ECG: sinus tachycardia;
presence of S1, Q3, and
T3More
D-dimer: non-specific if
positive; PE excluded if result
negative in patients with low
probability of having a PE
CXR: decreased perfusion in a
segment of pulmonary
vasculature (Westermark sign);
presence of pleural effusion
CT pulmonary
http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/148.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/116.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-29http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-6http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/148.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-7http://bestpractice.bmj.com/best-practice/monograph/116.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-29http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-28http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html -
7/27/2019 bol u grud uvod
10/17
angiography:identification of
thrombus in the pulmonary
circulationMore
Pneumonia
see our comprehensive coverage of Overview of pneumonia
History Exam 1st test
productive or dry cough, fever, pleuritic
pain associated with shortness of breath;
may have rigors, myalgias, and arthralgias;
recent history of travel or infectious
exposures[30]
decreased breath sounds, rales, wheezing,
bronchial breath sounds, dullness to
percussion, and increased tactile fremitus
observed with severe consolidation[30]
CXR: pulmonary infiltra
bronchograms, and ple
effusion
Viral pleuritis
History Exam 1st test
prodrome of viral illness (myalgias,
malaise, rhinorrhoea, cough, nasal
congestion, low-grade temperatures);
sick contacts
pleural friction rub with or without low-grade
fever; sometimes reproducible tenderness to
palpation of chest when perichondritis or
pleurodynia accompanies pleuritis
CXR: usually normal but
uncommonly have
effusionMore
GORD
see our comprehensive coverage of Gastro-oesophageal reflux disease
History Exam 1st test Other tests
retrosternal burning with eating large
or fatty meals that can be reproduced
with lying supine and relieved by
sitting up; relieved by antacids[33]
no specific
physical
findings
therapeutic trial: relief of
symptoms with short trial of
proton-pump inhibitors
Oesophagogas
inflammation or e
oesophageal pH
indicate reflux di
Costochondritis
see our comprehensive coverage of Costochondritis
History Exam 1st test
focal chest wall pain, may have known precipitating injury; aggravated
by sneezing, coughing, deep inspiration, or twisting of the chest
reproducible pain, especially at the
costochondral junctions
CXR
find
Anxiety or panic disorder
see our comprehensive coverage of Panic disorders
History Exam 1st test
sharp chest pain with anxiety, dizziness or faintness, palpitations, hyperventilation, ECG: normal
http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/1113.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/82.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-33http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-33http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-33http://bestpractice.bmj.com/best-practice/monograph/300.htmlhttp://bestpractice.bmj.com/best-practice/monograph/121.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/1113.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-30http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/82.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-33http://bestpractice.bmj.com/best-practice/monograph/300.htmlhttp://bestpractice.bmj.com/best-practice/monograph/121.html -
7/27/2019 bol u grud uvod
11/17
sweating, trembling or shaking, fear of dying or going insane,
paraesthesiae, chills or hot flushes, breathlessness or choking
sensation
examination otherwise
normal
Uncommonhide allPericarditis
see our comprehensive coverage of Pericarditis
History Exam 1st test Other
usually has viral prodrome; sharp pleuritic
chest discomfort provoked by lying supine
and improved with sitting up; associated dry
cough, fever, myalgias, or arthralgias; history
of possible causes such as radiation exposure,
collagen vascular disease, recent MI, or
uraemia
tachycardia and friction
rub; jugular venous
distention and pulsus
paradoxus indicate effusion
causing tamponade
ECG: diffuse concave-up ST-
elevation, associated PR
depression; changes evolve
over timeMore
Cardiac tamponadesee our comprehensive coverage of Cardiac tamponade
History Exam 1st test
history of underlying cause such as MI, aortic
dissection, or trauma; may present insidiously
as a result of hypothyroidism or pericarditis;
dizziness; dyspnoea; fatigue
hypotension, distended neck veins,
muffled heart sounds; pulsus
paradoxus (a drop of 10 mmHg in
arterial BP on inspiration)
ECG: low-voltage QRS; othe
underlying cause (e.g., ST el
specific ST changes in perica
CXR: globular heart (if large
echocardiography: pericard
of great vessels, atria, and ve
Aortic dissection
see our comprehensive coverage of Aortic dissection
History Exam 1st test O
acute substernal tearing sensation, with radiation
to interscapular region of the back; pain may
migrate with the propagation of the dissection;
stroke, acute MI due to obstruction of aortic
branches; dyspnoea due to acute aortic
regurgitation; hypotension due to cardiac
tamponade; history of hypertension, Marfan's
syndrome, Ehlers-Danlos syndrome, or
syphilis[24] [25]
unequal pulses or BPs in both arms; new
diastolic murmur due to aortic
regurgitation; muffled heart sounds if the
dissection is complicated by cardiac
tamponade; new focal neurological
findings due to involvement of the
carotid or vertebral arteries[24] [25]
CXR: widened
mediastinumMore
Aortic stenosis
http://bestpractice.bmj.com/best-practice/monograph/243.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/459.htmlhttp://bestpractice.bmj.com/best-practice/monograph/445.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/243.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/459.htmlhttp://bestpractice.bmj.com/best-practice/monograph/445.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-24http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-25http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.html -
7/27/2019 bol u grud uvod
12/17
see our comprehensive coverage of Aortic stenosis
History Exam 1st test Other
age over 60 years; typical angina; chest pain is
usually progressive;[27]shortness of breath;
syncope (if severe); patients with significant
aortic stenosis and heart failure are at high risk
of cardiogenic shock or sudden death
ejection systolic murmur
that radiates to the neck;
obliteration of S2 indicates
severe stenosis; delayed
upstroke on palpation of
carotid pulse
ECG: voltage criteria for
LVH; enlarged P wave
suggesting left atrial
enlargement
Mitral valve prolapse
see our comprehensive coverage of Mitral valve prolapse
History Exam 1st test Other tes
usually asymptomatic, but may cause
palpitations, chest pain, dyspnoea,
headache, or fatigue
mid-systolic click and
late systolic murmur at
the apex
ECG: usually normal, may show
atrial fibrillation or other arrhythmias
C
p
e
v
Pneumothorax
see our comprehensive coverage of Pneumothorax
History Exam 1st test
acute, pleuritic chest pain, shortness of breath; primary
spontaneous between ages 20 and 40 years; secondary
spontaneous in patients with COPD; traumatic due to acute
trauma or iatrogenic;[31] shock may occur if rapidly increasing
(tension pneumothorax)
absent breath sounds, increased resonance to
percussion; jugular venous distention, trachea
deviation, and hypotension if tension
pneumothorax (due to compromise of the great
vessels)[31]
Pulmonary hypertension
see our comprehensive coverage of Idiopathic pulmonary arterial hypertension
History Exam 1st test Other tests
cardiac-sounding chest pain on
exertion, dyspnoea; symptoms of
right-sided heart failure such as
lower extremity oedema,
abdominal bloating, or ascites;
syncope if severe[32]
accentuated pulmonic component
(P2) to the second heart sound;
palpable P2; right ventricular
heave; lower extremity oedema;
jugular venous distention
ECG: right axis
deviation; RVH or right
atrial enlargement
CXR: la
echoca
right ven
ventricu
effusion
Peptic ulcer disease (PUD)
see our comprehensive coverage of Peptic ulcer disease
History Exam 1st test
gastric ulcers: epigastric pain or burning with
onset 5 to 15 minutes after eating and may last
for several hours; duodenal ulcers: epigastric
pain is relieved by eating and may return 1 to 4
epigastric tenderness; if
significant bleeding is
present there may be
tachycardia,
Oesophagogastroduodenoscopy:ga
duodenal erosions or ulceration
http://bestpractice.bmj.com/best-practice/monograph/325.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-27http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-27http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-27http://bestpractice.bmj.com/best-practice/monograph/321.htmlhttp://bestpractice.bmj.com/best-practice/monograph/504.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/292.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/80.htmlhttp://bestpractice.bmj.com/best-practice/monograph/325.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-27http://bestpractice.bmj.com/best-practice/monograph/321.htmlhttp://bestpractice.bmj.com/best-practice/monograph/504.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-31http://bestpractice.bmj.com/best-practice/monograph/292.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-32http://bestpractice.bmj.com/best-practice/monograph/80.html -
7/27/2019 bol u grud uvod
13/17
hours postprandially; pain from any ulcer is
relieved by antacid; risk factors: cigarette
smoking, NSAIDs, and chronic alcohol
consumption[34]
hypotension, and
conjunctival pallor[34]
Oesophageal spasm
History Exam 1st test Othcrushing substernal chest pain, associated dysphagia,
pain does not always correlate with swallowing,
dysphagia precipitated by very hot or cold foods,
glyceryl trinitrate can relieve the pain[36]
no specific
findings
barium swallow: corkscrew or
rosary bead appearance on
barium swallow
Acute cholecystitis
see our comprehensive coverage of Cholecystitis
History Exam 1st test
right upper quadrant pain, radiation to
the interscapular area or right shoulder,
associated with nausea and vomiting,
fevers, anorexia often accompanies pain,
signs of peritoneal inflammation such as
abdominal pain with jarring[37]
right upper quadrant tenderness
(Murphy's sign), abdominal rigidity
and guarding if perforation of the
gallbladder, rarely have jaundice early
in the course of cholecystitis[37]
liver function tests: elevated
alkaline phosphatase and gammGT More
FBC: leukocytosis with a left
shiftMore
abdominal
ultrasound:pericholecystic fluid
distended gallbladder, thickened
gallbladder wall, and gallstones
Pancreatitis
see our comprehensive coverage of Acute pancreatitis
History Exam 1st test Other t
epigastric or periumbilical abdominal pain
that radiates to the back; may be severe;
associated nausea and vomiting; history of
alcohol consumption or gallstones[40]
tachycardic, hypotensive, febrile, acute
distress; ecchymosis in the
periumbilical region (Cullen's sign) and
the flank (Grey-Turner sign)
serum
lipase: double the
normal valuesMore
Herpes zoster
see our comprehensive coverage of Herpes zoster infection
History Exam 1st test Other
unilateral, burning pain in typical vesicular rash on erythematous usually no test
http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/78.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/66.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/23.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-34http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-36http://bestpractice.bmj.com/best-practice/monograph/78.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-37http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/66.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/references.html#ref-40http://bestpractice.bmj.com/best-practice/monograph/301/diagnosis/differential-diagnosis.htmlhttp://bestpractice.bmj.com/best-practice/monograph/23.html -
7/27/2019 bol u grud uvod
14/17
dermatome distribution that may occur
before appearance of rash and may persist
for >1 month
base, in unilateral distribution of
a dermatome
required:diagnosis is
clinical
Gastritis
see our comprehensive coverage of Gastritis
History Exam 1st testdyspepsia/epigastric discomfort; nausea,
vomiting, loss of appetite; history of
NSAID use or alcohol misuse; history
ofHelicobacter pyloriinfection; history of
previous gastric or abdominal surgery
epigastric gastric discomfort may be
present; may have signs associated with
vitamin B12 deficiency and pernicious
anaemia (e.g., abnormal neurological
examination, presence of cognitive
impairment, angular cheilitis, atrophic
glossitis
Helicobacter pylori urea
breath test: positive in H
pyloriinfection
Email
Print
FeedbackShare
Add to Portfolio
Bookmark
Add notes
ST changes associated with ischaemia
Courtesy of Dr Francis Morris
http://bestpractice.bmj.com/best-practice/monograph/816.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/301/resources/images/print/1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/feedback/301/resources/images/print/1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/share/301/resources/images/print/1-2-4-5-6-7.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Chest+pain+(Assessment+of)+-+resources.images.print&dataValue=%2Fbest-practice%2Fmonograph%2F301%2Fresources%2Fimages%2Fprint%2F1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/monograph/816.htmlhttp://bestpractice.bmj.com/best-practice/emailfriend/301/resources/images/print/1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/feedback/301/resources/images/print/1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/share/301/resources/images/print/1-2-4-5-6-7.htmlhttp://portfolio.bmj.com/portfolio/add-to-portfolio.html?u=%3C;url%3Ehttp://bestpractice.bmj.com/best-practice/mybp/mybpSave.html?category=bookmark&dataKey=Chest+pain+(Assessment+of)+-+resources.images.print&dataValue=%2Fbest-practice%2Fmonograph%2F301%2Fresources%2Fimages%2Fprint%2F1-2-4-5-6-7.htmlhttp://bestpractice.bmj.com/best-practice/monograph/301/resources/images/print/1-2-4-5-6-7.html -
7/27/2019 bol u grud uvod
15/17
T-wave changes with ischaemia
Courtesy of Dr Channer
ECG showing changes of an acute inferior MI with ST elevation in leads II, III and aVF
-
7/27/2019 bol u grud uvod
16/17
Used with permission from Professor James Brown
ECG showing diffuse concave upwards ST elevation with associated PR depression suggestive of pericarditis
Used with permission from Professor James Brown
Spiral CT pulmonary angiogram showing a large filling defect within the pulmonary vasculature compatible with a
saddle embolus
Used with permission from Professor James Brown
-
7/27/2019 bol u grud uvod
17/17
CXR showing a widened mediastinum
Used with permission from Professor James Brown
1