Back pain and pulse deficit

Jump to navigation Jump to search

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

Abbreviations: ABG = Arterial blood gases, ANA = Antinuclear antibodies, BUN = Blood urea nitrogen, CRP = C-reactive protein, CT = Computed tomography, DRA = Dual energy radiographic absorptiometry, DRE = Digital rectal exam, ERCP = Endoscopic retrograde cholangiopancreatography, ESR = Erythrocyte sedimentation rate, HSV = Herpes simplex virus, IVP = Intravenous pyelography, KUB = Kidney, bladder, ureter, LDH = Lactate dehydrogenase, LFT = Liver function test, MRA = Magnetic resonance angiography, MRC = Magnetic resonance cholangiopancreatography, MRI = Magnetic resonance imaging, MRU = Magnetic resonance urography, NSAIDs = Non-steroidal anti-inflammatory drugs, PCR = Polymerase chain reaction, PET - FDG = Positive emission tomography - fluorodeoxyglucose, PET = Positive emission tomography, PID = Pelvic inflammatory disease, PSA = Prostatic specific antigen, PTC = Percutaneous transhepatic cholangiography, RUQ = Right upper quadrant, SPECT = Single-photon emission computed tomography, TFT = Thyroid function test, VZV = Varicella zoster virus

Classification of pain in the back based on etiology Diease Clinical Manifestation Diagnosis Comments
Symptoms Signs Lab findings Imaging
Onset Duration Quality of pain Radiation Stiffness Fever Rigors and chills Headache Nausea and vomiting Syncopy Weight loss Motor weakness Sensory deficit Pulse Deficit Heart Murmur Bowel or bladder dysfunction Horner's syndrome
Referred pain Aortic aneurysm

rupture[1][2][3] - Abdominal aortic aneurysm

- Thoracic aortic aneurysm

Acute Minutes to hours Sharp and knife-like, also tearing or ripping Back and/ or flanks - - - - - +/- - - - + +/- - - Typically no specific lab findings, however, evidence of haemorrhage and organ injury may be seen in: Ultrasonography
  • Visualization of aneurysm, size and/or rupture and hematoma

Chest radiography

  • Visualizes calcifications in aneurysm but not specific

CT

  • Demonstrates aortic size, extent, and involvement of organ arteries

MRI

  • Has advantage of less radiation and no use for dye, whilst demonstrating same findings as ultrasound and CT

Angiography

  • Allows 3D construction of aorta

Echocardiography (Transesophageal)

  • Demonstrates fluid shift and need for cardiology intervention
Aortic dissection[4][5][6][6][7][8] Severe and sudden (acute) and rarely, chronic Minutes to hours Sharp and knife-like, also tearing or ripping Back and/or flanks - - - - - +/- - - - + +/- - - Elevations in:
  • D - dimer
  • Smooth muscle myosin heavy chain
  • Soluble ST2
  • Soluble elastin fragments
  • High -sensitivity C-reactive protein
  • Fibrinogen
  • Fibrillin fragments
ECG:
  • Normal
  • Non - specific ST wave changes
  • Hypertrophy patterns
  • ST segment elevation indicating myocardial infarction

Chest radiography:

  • Normal
  • Mediastinal or aortic widening
Chronic stable angina[9][10] Chronic Variable Discomfort in the chest Left shoulder, arm and jaw - - - - +/- +/- - - - +/- - - - Detection of:
  • Urinary proton nuclear magnetic resonance spectroscopy
  • Toll-like receptors 2 and 4 (TLR-2 and TLR-4)  on platelets
Chest radiography

Exercise stress testing

  • Establishes diagnosis and extent of angina

Stress Echo

Nuclear imaging

CT

  • To evaluate coronary artery calcium (cac) which may or may not be elevated

CT Angiography

EKG

Endocarditis[11][12][13] Acute or subacute Variable Discomfort in the chest Jaw and arms - +/- +/- - +/- +/- - - - +/- + - - CBC

Serology

ESR

  • May be elevated

Urine analysis

Blood culture

  • To identify causative agent
  • Streptococci and HACEK organisms are culture negative
  • Organisms that grow on prosthetic valves tend to be coagulase-negative staphylococci
Echocardiography
  • Vegetations and myocardial abscesses may be present

Radiography

  • Pyogenic emboli may be seen across the lung field

Ultrasound

  • Myocardial abscesses may be seen
  • Valvular dysfunction may also be noted
Pulmonary embolism[14][15][16] Acute Minutes Severe, sharp Chest and back +/- - - +/- +/- +/- - - - +/- +/- - - Lab findings are not specfic and are done to rule out other diseases such as:
  • D - dimer is positive and ventilation- perfusion scanning will show a a perfusion/ventilation mismatch
  • CT Angiography and duplex angiography are able to visualize the embolism
  • PE may occur even in patients that are fully anticoagulated
  • DVT is a common source
Traumatic aortic rupture[17][18] Acute Minutes to hours Sharp and knife-like, also tearing or ripping Back and/ or flanks - - - - - +/- - - - +/- +/- - - Typically no specific lab findings, however, evidence of hemorrhage and organ injury may be seen in: Ultrasonography
  • Visualization of rupture, size and hematoma

CT

  • Demonstrates intimal flap, hematoma, filling defect, aortic contour abnormality, pseudoaneurysm, vessel wall disruption, and extravasation of intravenous contrast

MRI

  • Has advantage of less radiation and no use for dye, whilst demonstrating same findings as ultrasound and CT

Angiography

  • Allows 3D construction of aorta

Echocardiography (Transesophageal)

  • Demonstrates fluid shift and need for cardiology intervention
  • Mostly caused by automobile accidents





References

  1. Chaikof EL, Brewster DC, Dalman RL, Makaroun MS, Illig KA, Sicard GA, Timaran CH, Upchurch GR, Veith FJ (October 2009). "The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines". J. Vasc. Surg. 50 (4 Suppl): S2–49. doi:10.1016/j.jvs.2009.07.002. PMID 19786250.
  2. Sullivan CA, Rohrer MJ, Cutler BS (June 1990). "Clinical management of the symptomatic but unruptured abdominal aortic aneurysm". J. Vasc. Surg. 11 (6): 799–803. PMID 2359191.
  3. Lesperance K, Andersen C, Singh N, Starnes B, Martin MJ (June 2008). "Expanding use of emergency endovascular repair for ruptured abdominal aortic aneurysms: disparities in outcomes from a nationwide perspective". J. Vasc. Surg. 47 (6): 1165–70, discussion 1170–1. doi:10.1016/j.jvs.2008.01.055. PMID 18394857.
  4. Suzuki T, Distante A, Eagle K (November 2010). "Biomarker-assisted diagnosis of acute aortic dissection: how far we have come and what to expect". Curr. Opin. Cardiol. 25 (6): 541–5. doi:10.1097/HCO.0b013e32833e6e13. PMID 20717014.
  5. Wang Y, Tan X, Gao H, Yuan H, Hu R, Jia L, Zhu J, Sun L, Zhang H, Huang L, Zhao D, Gao P, Du J (January 2018). "Magnitude of Soluble ST2 as a Novel Biomarker for Acute Aortic Dissection". Circulation. 137 (3): 259–269. doi:10.1161/CIRCULATIONAHA.117.030469. PMID 29146682.
  6. 6.0 6.1 Akutsu K, Yamanaka H, Katayama M, Yamamoto T, Takayama M, Osaka M, Sato N, Shimizu W (November 2016). "Usefulness of Measuring the Serum Elastin Fragment Level in the Diagnosis of an Acute Aortic Dissection". Am. J. Cardiol. 118 (9): 1405–1409. doi:10.1016/j.amjcard.2016.07.052. PMID 27666178.
  7. Suzuki T, Katoh H, Tsuchio Y, Hasegawa A, Kurabayashi M, Ohira A, Hiramori K, Sakomura Y, Kasanuki H, Hori S, Aikawa N, Abe S, Tei C, Nakagawa Y, Nobuyoshi M, Misu K, Sumiyoshi T, Nagai R (October 2000). "Diagnostic implications of elevated levels of smooth-muscle myosin heavy-chain protein in acute aortic dissection. The smooth muscle myosin heavy chain study". Ann. Intern. Med. 133 (7): 537–41. PMID 11015167.
  8. Marshall LM, Carlson EJ, O'Malley J, Snyder CK, Charbonneau NL, Hayflick SJ, Coselli JS, Lemaire SA, Sakai LY (October 2013). "Thoracic aortic aneurysm frequency and dissection are associated with fibrillin-1 fragment concentrations in circulation". Circ. Res. 113 (10): 1159–68. doi:10.1161/CIRCRESAHA.113.301498. PMID 24036495.
  9. Kreiner M, Okeson JP, Michelis V, Lujambio M, Isberg A (January 2007). "Craniofacial pain as the sole symptom of cardiac ischemia: a prospective multicenter study". J Am Dent Assoc. 138 (1): 74–9. PMID 17197405.
  10. Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L (January 1985). "Acute chest pain in the emergency room. Identification and examination of low-risk patients". Arch. Intern. Med. 145 (1): 65–9. PMID 3970650.
  11. Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, Dulgheru R, El Khoury G, Erba PA, Iung B, Miro JM, Mulder BJ, Plonska-Gosciniak E, Price S, Roos-Hesselink J, Snygg-Martin U, Thuny F, Tornos Mas P, Vilacosta I, Zamorano JL (November 2015). "2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM)". Eur. Heart J. 36 (44): 3075–3128. doi:10.1093/eurheartj/ehv319. PMID 26320109.
  12. Meine TJ, Nettles RE, Anderson DJ, Cabell CH, Corey GR, Sexton DJ, Wang A (August 2001). "Cardiac conduction abnormalities in endocarditis defined by the Duke criteria". Am. Heart J. 142 (2): 280–5. doi:10.1067/mhj.2001.116964. PMID 11479467.
  13. Cahill TJ, Prendergast BD (February 2016). "Infective endocarditis". Lancet. 387 (10021): 882–93. doi:10.1016/S0140-6736(15)00067-7. PMID 26341945.
  14. Lassila R, Jula A, Pitkäniemi J, Haukka J (November 2014). "The association of statin use with reduced incidence of venous thromboembolism: a population-based cohort study". BMJ Open. 4 (11): e005862. doi:10.1136/bmjopen-2014-005862. PMC 4225235. PMID 25377011.
  15. Horlander KT, Mannino DM, Leeper KV (July 2003). "Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause mortality data". Arch. Intern. Med. 163 (14): 1711–7. doi:10.1001/archinte.163.14.1711. PMID 12885687.
  16. Carson JL, Kelley MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, Schwartz JS, Thompson BT, Popovich J, Hobbins TE (May 1992). "The clinical course of pulmonary embolism". N. Engl. J. Med. 326 (19): 1240–5. doi:10.1056/NEJM199205073261902. PMID 1560799.
  17. Dyer DS, Moore EE, Ilke DN, McIntyre RC, Bernstein SM, Durham JD, Mestek MF, Heinig MJ, Russ PD, Symonds DL, Honigman B, Kumpe DA, Roe EJ, Eule J (April 2000). "Thoracic aortic injury: how predictive is mechanism and is chest computed tomography a reliable screening tool? A prospective study of 1,561 patients". J Trauma. 48 (4): 673–82, discussion 682–3. PMID 10780601.
  18. Mirvis SE, Shanmuganathan K, Buell J, Rodriguez A (November 1998). "Use of spiral computed tomography for the assessment of blunt trauma patients with potential aortic injury". J Trauma. 45 (5): 922–30. PMID 9820704.