1/28. Differential diagnosis of chest pain: a case report.chest pain in a common presenting complaint in many healthcare settings, including Gl settings. It may be caused by a variety of cardiac and noncardiac abnormalities. nurses can play a critical role in the differential diagnosis of chest pain by obtaining a thorough history and conducting a directed physical examination. This article describes the differential diagnosis of chest pain through a case presentation.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
2/28. Musculoskeletal causes of chest pain.BACKGROUND: chest pain is a common presenting problem to general practitioners and accident and emergency departments. Such a symptom generates anxiety in both patients and their medical attendants, for fear that this symptom represents a life threatening event. Numerous investigations often ensue, adding to the physical and financial burden on an already stressed health system. Musculoskeletal causes of chest pain are common but frequently overlooked. OBJECTIVE: This article aims to outline some of the more common musculoskeletal problems which may present as chest pain, and to present a practical approach to their diagnosis and management. DISCUSSION: It is estimated that somewhere in the vicinity of 20-25% of noncardiac chest pain has a musculoskeletal basis. Careful history taking to identify red flag conditions differentiates those who require further investigation. Historical features suggesting a musculoskeletal cause include pain on specific postures or physical activities. A musculoskeletal diagnosis can usually be confirmed by clinical examination alone, the key to which is reproducing the patient's pain by either a movement or more specifically palpation over the structure that is the source of the pain. Confirming the diagnosis, explanation and reassurance allay anxiety. Management strategies include manual therapy, the provision of analgesia and anti-inflammatory agents, either topically, orally or by injection. Focal injection of local anaesthetic alone may also be a useful diagnostic and therapeutic tool.- - - - - - - - - - ranking = 0.24521234411271keywords = physical (Clic here for more details about this article) |
3/28. chiropractic management of chronic chest pain using mechanical force, manually assisted short-lever adjusting procedures.OBJECTIVE: To discuss a case involving a patient with chronic chest pain, dyspnea, and anxiety. Although resistant to previous treatment regimens, the condition responded favorably to chiropractic manipulation of the costosternal articulations. CLINICAL FEATURES: A 49-year-old man had chronic chest pain, dyspnea, and anxiety for over 4 months. The severity of the condition gradually progressed to the point of precluding the patient's active employment and most physical activity. Prior efforts to treat the condition had met with failure. INTERVENTION AND OUTCOME: The patient received mechanical force, manually assisted short-lever chiropractic adjustment of the thoracic spine and, in particular, the costosternal articulations. Adjustments were by means of an Activator Adjusting Instrument II. The patient responded favorably to the intervention, obtaining prompt relief from his symptoms. Sustained chiropractic care rendered over a 14-week period resulted in complete resolution of the patient's previously chronic condition, with recovery maintained at 9-month follow-up. CONCLUSIONS: Certain types of chest pain may have their etiology in a subluxation complex involving the costosternal articulation. Although the possibility of myocardial involvement must be considered with all patients whose symptoms include chest pain, a musculoskeletal involvement, including costosternal subluxation complex, may be the underlying cause of the symptoms in certain patients. When this is the case, chiropractic adjustment may provide an effective mode of treatment. Further study in an academic research venue is merited to investigate the role that conservative chiropractic care can provide for patients with chest pain.- - - - - - - - - - ranking = 0.12260617205636keywords = physical (Clic here for more details about this article) |
4/28. Costovertebral joint dysfunction: another misdiagnosed cause of atypical chest pain.The diagnostic work-up of atypical chest pain frequently leads to invasive procedures. However, this painful symptomatology can sometimes be of benign origin and respond to simple therapeutic manoeuvres. A number of musculoskeletal conditions such as costovertebral joint dysfunctions should be carefully considered. We report five cases in which patient discomfort and high costs could have been avoided if awareness of these conditions had led to a correct diagnosis upon initial physical examination.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
5/28. Idiopathic spontaneous pneumomediastinum: an uncommon emergency in children.Spontaneous pneumomediastinum (SPM) occurs rarely in children. The diagnosis is based on physical examination and chest radiography. Conservative therapy usually leads to recovery. However, SPM in association with severe hypoxia, tachycardia, metabolic acidosis, and high ventilation pressures indicates clinically significant tension in the mediastinum. A collar mediastinotomy is the treatment of choice in these circumstances.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
6/28. A case of hereditary angioedema with recurrent arthritis, erythema marginatum-like rash and chest pain.Hereditary angioedema (HAE) results from a congenital deficiency of C1 inhibitor and is characterized by submucosal and subcutaneous edema of skin, larynx and abdomen. Occasional reports have appeared linking HAE with autoimmune diseases. We report a case of HAE presenting recurrent nondeforming polyarthritis, erythema marginatum-like rash and chest pain. There were no significant radiographic joint changes. serologic tests for rheumatologic and autoimmune diseases were negative. After danazol treatment, physical examination and laboratory findings were normal over five years. We suggest that pediatricians should be aware of this rare disease and treat patients accordingly.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
7/28. Cases from the Osler Medical Service at Johns Hopkins University. diagnosis: P. carinii pneumonia and primary pulmonary sporotrichosis.PRESENTING FEATURES: A 53-year-old man who had human immunodeficiency virus (hiv) presented to the Johns Hopkins Hospital with a 3-month history of increasing dysphagia, cough, dyspnea, chest pain, and an episode of syncope. His past medical history was notable for oral and presumptive esophageal candidiasis that was treated with fluconazole 6 months prior to presentation. Three months prior to presentation, he discontinued his medications, and his symptoms of dysphagia recurred. During that time he developed intermittent fevers and chills, progressively worsening dyspnea on exertion, and a cough productive of white sputum. He also reported a 40-lb weight loss over the past 3 months. On the day prior to presentation, he had chest pain and shortness of breath followed by weakness, dizziness, and a brief syncopal episode. He denied orthopnea, paroxysmal nocturnal dyspnea, lower extremity edema, jaundice, hemoptysis, hematemesis, melena, hematochezia, or diarrhea. There was no history of alcohol use, and he stopped smoking tobacco approximately 1 month previously. He smoked cocaine but denied injection drug use. The patient had never been on antiretroviral therapy and had never had his CD4 count or viral load measured. On physical examination, the patient was a thin, cachectic man who appeared older than his stated age. His vital signs were notable for blood pressure of 102/69 mm Hg, resting tachycardia of 102 beats per minute, resting oxygen saturation of 92% on room air, normal resting respiratory rate, and a temperature of 38.1 degrees C. His oropharynx was clear, with no signs of thrush or mucosal ulcers. His pulmonary examination was notable for diminished breath sounds in the lower lung fields bilaterally. Cardiac, abdominal, and neurologic examinations were normal. His skin was intact, with no visible petechiae, rashes, nodules, or ulcers. Laboratory studies showed a total white blood cell count of 3.2 x 10(3)/microL, with a total lymphocyte count of 330/microL, hematocrit of 30.2%, a serum sodium level of 129 mEq/L, and a serum lactate dehydrogenase level of 219 IU/L. The patient had an absolute CD4 count of 8 cells/mm3 and a hiv viral load of 86,457 copies/mL. His arterial blood gas on room air had a pH of 7.51, a PCO2 of 33 mm Hg, and a PO2 of 55 mm Hg. Electrocardiogram and serial serum cardiac enzymes were normal. A chest radiograph showed bilateral upper lobe patchy infiltrates with left upper lobe consolidation. Computed tomographic (CT) scan of the chest with contrast showed bilateral ground glass infiltrates with focal consolidation (Figure 1) and no evidence of pulmonary embolism. Induced sputum was negative for pneumocystis carinii, fungi, or acid-fast bacilli. A bronchoalveolar lavage was performed. What is the diagnosis?- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
8/28. A case of transient left ventricular apical ballooning. A condition simulating an acute myocardial infarction.Transient left ventricular apical ballooning, sometimes associated with intraventricular pressure gradient, is a condition simulating an acute myocardial infarction and may occur in patients presenting with chest pain, electrocardiographic changes and minimal myocardial enzyme release typically without coronary angiographic stenosis. It was originally described in the Japanese population and is often associated with cerebrovascular accidents, surgical procedures and emotional and physical stress. We report the case of a 65-year-old woman presenting with chest pain typical of myocardial ischemia, dyspnea, electrocardiographic abnormalities and signs of hemodynamic instability, occurring after a severe emotional stress. echocardiography and contrast ventriculography showed normokinesis confined to the basal segments of the left ventricle, with a markedly decreased ejection fraction. Scintigraphy was suggestive of a large perfusion defect. The electrocardiographic abnormalities and dyskinesis persisted for many hours. coronary angiography, performed in the acute phase, was completely normal. Five months later, the functional and electrocardiographic abnormalities had totally disappeared.- - - - - - - - - - ranking = 0.12260617205636keywords = physical (Clic here for more details about this article) |
9/28. coronary-subclavian steal syndrome presenting with chest pain and syncope.The present case is a 68-year-old patient with complaints of chest pain and syncopal attacks during physical activity of the left arm, for the last six months. He had a coronary artery bypass graft operation 10 years ago. Angiographic examination demonstrated total occlusion of the subclavian artery. The subclavian artery was stealing blood from the left anterior descending artery via the left internal mammary artery and from the brain via the left vertebral artery, leading to the diagnosis of subclavian artery steal syndrome; a rare cause of coronary and cerebral ischaemia.- - - - - - - - - - ranking = 0.12260617205636keywords = physical (Clic here for more details about this article) |
10/28. The electrocardiographic toxidrome: the ECG presentation of hydrofluoric acid ingestion.The clinician can approach the poisoned patient using the toxidrome system of toxin identification; this approach makes use of findings noted on the physical examination, highlighting the importance of abnormalities in blood pressure, heart rate, respiratory effort, body temperature, mental status, pupillary size, skin color, diaphoresis, and gastrointestinal sounds. Such a method provides structure and guidance to the clinical evaluation, providing the clinician with rapid diagnostic information and suggesting urgent management issues. A case of hydrofluoric acid poisoning is used as an example of this diagnostic approach. The patient demonstrated systemic toxicity accompanied by oral irritation and electrocardiographic abnormality (QRS complex widening and QT interval prolongation). The constellation of these findings suggested the possibility of a caustic agent (history and examination) with potential effect on potassium and calcium metabolism (electrocardiographic abnormalities). Such a constellation strongly suggested hydrofluoric acid as the culprit toxin.- - - - - - - - - - ranking = 1keywords = physical examination, physical (Clic here for more details about this article) |
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