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==Overview==
==Overview==
There are several life-threatening causes of back pain which need to be evaluated for first, which include; spinal cord or cauda equina compression, aortic dissection, aortic aneurysm, vertebral osteomyelitis, epidural abscess, and metastatic cancer. The other possible causes of back pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history.<ref name="pmid21282698">{{cite journal |vauthors=Chou R, Qaseem A, Owens DK, Shekelle P |title=Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians |journal=Ann. Intern. Med. |volume=154 |issue=3 |pages=181–9 |date=February 2011 |pmid=21282698 |doi=10.7326/0003-4819-154-3-201102010-00008 |url=}}</ref><ref name="pmid9270576">{{cite journal |vauthors=Schiff D, O'Neill BP, Suman VJ |title=Spinal epidural metastasis as the initial manifestation of malignancy: clinical features and diagnostic approach |journal=Neurology |volume=49 |issue=2 |pages=452–6 |date=August 1997 |pmid=9270576 |doi= |url=}}</ref><ref name="pmid2967893">{{cite journal |vauthors=Deyo RA, Diehl AK |title=Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies |journal=J Gen Intern Med |volume=3 |issue=3 |pages=230–8 |date=1988 |pmid=2967893 |doi= |url=}}</ref>
There are several life-threatening causes of back pain which need to be evaluated for first, which include; spinal cord or cauda equina compression, aortic dissection, aortic aneurysm, vertebral osteomyelitis, epidural abscess, and metastatic cancer. The other possible causes of back pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history.


==Differential Diagnosis==
==Differential Diagnosis==
*5 life threatening diseases to exclude immediately:<ref name="pmid24150427">{{cite journal |vauthors=Sun JC, Xu T, Chen KF, Qian W, Liu K, Shi JG, Yuan W, Jia LS |title=Assessment of cauda equina syndrome progression pattern to improve diagnosis |journal=Spine |volume=39 |issue=7 |pages=596–602 |date=April 2014 |pmid=24150427 |doi=10.1097/BRS.0000000000000079 |url=}}</ref><ref name="pmid9270576">{{cite journal |vauthors=Schiff D, O'Neill BP, Suman VJ |title=Spinal epidural metastasis as the initial manifestation of malignancy: clinical features and diagnostic approach |journal=Neurology |volume=49 |issue=2 |pages=452–6 |date=August 1997 |pmid=9270576 |doi= |url=}}</ref><ref name="pmid2967893">{{cite journal |vauthors=Deyo RA, Diehl AK |title=Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies |journal=J Gen Intern Med |volume=3 |issue=3 |pages=230–8 |date=1988 |pmid=2967893 |doi= |url=}}</ref><ref name="pmid12353946">{{cite journal |vauthors=Jarvik JG, Deyo RA |title=Diagnostic evaluation of low back pain with emphasis on imaging |journal=Ann. Intern. Med. |volume=137 |issue=7 |pages=586–97 |date=October 2002 |pmid=12353946 |doi= |url=}}</ref><ref name="pmid8542211">{{cite journal |vauthors=Underwood MR, Dawes P |title=Inflammatory back pain in primary care |journal=Br. J. Rheumatol. |volume=34 |issue=11 |pages=1074–7 |date=November 1995 |pmid=8542211 |doi= |url=}}</ref><ref name="pmid7987418">{{cite journal |vauthors= |title=Acute low back problems in adults: assessment and treatment. Agency for Health Care Policy and Research |journal=Clin Pract Guidel Quick Ref Guide Clin |volume= |issue=14 |pages=iii–iv, 1–25 |date=December 1994 |pmid=7987418 |doi= |url=}}</ref><ref name="pmid25806916">{{cite journal |vauthors=Ropper AH, Zafonte RD |title=Sciatica |journal=N. Engl. J. Med. |volume=372 |issue=13 |pages=1240–8 |date=March 2015 |pmid=25806916 |doi=10.1056/NEJMra1410151 |url=}}</ref><ref name="pmid25844995">{{cite journal |vauthors=Delitto A, Piva SR, Moore CG, Fritz JM, Wisniewski SR, Josbeno DA, Fye M, Welch WC |title=Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial |journal=Ann. Intern. Med. |volume=162 |issue=7 |pages=465–73 |date=April 2015 |pmid=25844995 |doi=10.7326/M14-1420 |url=}}</ref><ref name="pmid15062719">{{cite journal |vauthors=Papadopoulos EC, Khan SN |title=Piriformis syndrome and low back pain: a new classification and review of the literature |journal=Orthop. Clin. North Am. |volume=35 |issue=1 |pages=65–71 |date=January 2004 |pmid=15062719 |doi=10.1016/S0030-5898(03)00105-6 |url=}}</ref><ref name="pmid20596735">{{cite journal |vauthors=Hopayian K, Song F, Riera R, Sambandan S |title=The clinical features of the piriformis syndrome: a systematic review |journal=Eur Spine J |volume=19 |issue=12 |pages=2095–109 |date=December 2010 |pmid=20596735 |pmc=2997212 |doi=10.1007/s00586-010-1504-9 |url=}}</ref><ref name="pmid2932746">{{cite journal |vauthors=Potter NA, Rothstein JM |title=Intertester reliability for selected clinical tests of the sacroiliac joint |journal=Phys Ther |volume=65 |issue=11 |pages=1671–5 |date=November 1985 |pmid=2932746 |doi= |url=}}</ref><ref name="pmid7326071">{{cite journal |vauthors=Russel AS, Maksymowych W, LeClercq S |title=Clinical examination of the sacroiliac joints: a prospective study |journal=Arthritis Rheum. |volume=24 |issue=12 |pages=1575–7 |date=December 1981 |pmid=7326071 |doi= |url=}}</ref>
*5 life threatening diseases to exclude immediately:<ref name="pmid21282698">{{cite journal |vauthors=Chou R, Qaseem A, Owens DK, Shekelle P |title=Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians |journal=Ann. Intern. Med. |volume=154 |issue=3 |pages=181–9 |date=February 2011 |pmid=21282698 |doi=10.7326/0003-4819-154-3-201102010-00008 |url=}}</ref><ref name="pmid9270576">{{cite journal |vauthors=Schiff D, O'Neill BP, Suman VJ |title=Spinal epidural metastasis as the initial manifestation of malignancy: clinical features and diagnostic approach |journal=Neurology |volume=49 |issue=2 |pages=452–6 |date=August 1997 |pmid=9270576 |doi= |url=}}</ref><ref name="pmid2967893">{{cite journal |vauthors=Deyo RA, Diehl AK |title=Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies |journal=J Gen Intern Med |volume=3 |issue=3 |pages=230–8 |date=1988 |pmid=2967893 |doi= |url=}}</ref><ref name="pmid24150427">{{cite journal |vauthors=Sun JC, Xu T, Chen KF, Qian W, Liu K, Shi JG, Yuan W, Jia LS |title=Assessment of cauda equina syndrome progression pattern to improve diagnosis |journal=Spine |volume=39 |issue=7 |pages=596–602 |date=April 2014 |pmid=24150427 |doi=10.1097/BRS.0000000000000079 |url=}}</ref><ref name="pmid9270576">{{cite journal |vauthors=Schiff D, O'Neill BP, Suman VJ |title=Spinal epidural metastasis as the initial manifestation of malignancy: clinical features and diagnostic approach |journal=Neurology |volume=49 |issue=2 |pages=452–6 |date=August 1997 |pmid=9270576 |doi= |url=}}</ref><ref name="pmid2967893">{{cite journal |vauthors=Deyo RA, Diehl AK |title=Cancer as a cause of back pain: frequency, clinical presentation, and diagnostic strategies |journal=J Gen Intern Med |volume=3 |issue=3 |pages=230–8 |date=1988 |pmid=2967893 |doi= |url=}}</ref><ref name="pmid12353946">{{cite journal |vauthors=Jarvik JG, Deyo RA |title=Diagnostic evaluation of low back pain with emphasis on imaging |journal=Ann. Intern. Med. |volume=137 |issue=7 |pages=586–97 |date=October 2002 |pmid=12353946 |doi= |url=}}</ref><ref name="pmid8542211">{{cite journal |vauthors=Underwood MR, Dawes P |title=Inflammatory back pain in primary care |journal=Br. J. Rheumatol. |volume=34 |issue=11 |pages=1074–7 |date=November 1995 |pmid=8542211 |doi= |url=}}</ref><ref name="pmid7987418">{{cite journal |vauthors= |title=Acute low back problems in adults: assessment and treatment. Agency for Health Care Policy and Research |journal=Clin Pract Guidel Quick Ref Guide Clin |volume= |issue=14 |pages=iii–iv, 1–25 |date=December 1994 |pmid=7987418 |doi= |url=}}</ref><ref name="pmid25806916">{{cite journal |vauthors=Ropper AH, Zafonte RD |title=Sciatica |journal=N. Engl. J. Med. |volume=372 |issue=13 |pages=1240–8 |date=March 2015 |pmid=25806916 |doi=10.1056/NEJMra1410151 |url=}}</ref><ref name="pmid25844995">{{cite journal |vauthors=Delitto A, Piva SR, Moore CG, Fritz JM, Wisniewski SR, Josbeno DA, Fye M, Welch WC |title=Surgery versus nonsurgical treatment of lumbar spinal stenosis: a randomized trial |journal=Ann. Intern. Med. |volume=162 |issue=7 |pages=465–73 |date=April 2015 |pmid=25844995 |doi=10.7326/M14-1420 |url=}}</ref><ref name="pmid15062719">{{cite journal |vauthors=Papadopoulos EC, Khan SN |title=Piriformis syndrome and low back pain: a new classification and review of the literature |journal=Orthop. Clin. North Am. |volume=35 |issue=1 |pages=65–71 |date=January 2004 |pmid=15062719 |doi=10.1016/S0030-5898(03)00105-6 |url=}}</ref><ref name="pmid20596735">{{cite journal |vauthors=Hopayian K, Song F, Riera R, Sambandan S |title=The clinical features of the piriformis syndrome: a systematic review |journal=Eur Spine J |volume=19 |issue=12 |pages=2095–109 |date=December 2010 |pmid=20596735 |pmc=2997212 |doi=10.1007/s00586-010-1504-9 |url=}}</ref><ref name="pmid2932746">{{cite journal |vauthors=Potter NA, Rothstein JM |title=Intertester reliability for selected clinical tests of the sacroiliac joint |journal=Phys Ther |volume=65 |issue=11 |pages=1671–5 |date=November 1985 |pmid=2932746 |doi= |url=}}</ref><ref name="pmid7326071">{{cite journal |vauthors=Russel AS, Maksymowych W, LeClercq S |title=Clinical examination of the sacroiliac joints: a prospective study |journal=Arthritis Rheum. |volume=24 |issue=12 |pages=1575–7 |date=December 1981 |pmid=7326071 |doi= |url=}}</ref><ref name="pmid10534797">{{cite journal |vauthors=Levangie PK |title=Four clinical tests of sacroiliac joint dysfunction: the association of test results with innominate torsion among patients with and without low back pain |journal=Phys Ther |volume=79 |issue=11 |pages=1043–57 |date=November 1999 |pmid=10534797 |doi= |url=}}</ref><ref name="pmid12147007">{{cite journal |vauthors=Riddle DL, Freburger JK |title=Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter intertester reliability study |journal=Phys Ther |volume=82 |issue=8 |pages=772–81 |date=August 2002 |pmid=12147007 |doi= |url=}}</ref><ref name="pmid17304687">{{cite journal |vauthors=Irwin RW, Watson T, Minick RP, Ambrosius WT |title=Age, body mass index, and gender differences in sacroiliac joint pathology |journal=Am J Phys Med Rehabil |volume=86 |issue=1 |pages=37–44 |date=January 2007 |pmid=17304687 |doi= |url=}}</ref><ref name="pmid26484005">{{cite journal |vauthors=Jancuska JM, Spivak JM, Bendo JA |title=A Review of Symptomatic Lumbosacral Transitional Vertebrae: Bertolotti's Syndrome |journal=Int J Spine Surg |volume=9 |issue= |pages=42 |date=2015 |pmid=26484005 |pmc=4603258 |doi=10.14444/2042 |url=}}</ref>
 
**Spinal cord or cauda equina compression  
**Spinal cord or cauda equina compression  
**[[Aortic dissection]]
**[[Aortic dissection]]
Line 30: Line 29:
**Piriformis syndrome  
**Piriformis syndrome  
**Sacroiliac joint dysfunction
**Sacroiliac joint dysfunction
**Bertolotti's syndrome  
**Bertolotti's syndrome (Lumbosacral transitional vertebrae)


===Differential Diagnosis of Back Pain:===
===Differential Diagnosis of Back Pain:===

Revision as of 16:39, 5 March 2018

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


An expert algorithm to assist in the diagnosis of back pain can be found here

Overview

There are several life-threatening causes of back pain which need to be evaluated for first, which include; spinal cord or cauda equina compression, aortic dissection, aortic aneurysm, vertebral osteomyelitis, epidural abscess, and metastatic cancer. The other possible causes of back pain can be evaluated for by carefully assessing the nature of the pain, and obtaining a thorough patient history.

Differential Diagnosis

  • 5 life threatening diseases to exclude immediately:[1][2][3][4][2][3][5][6][7][8][9][10][11][12][13][14][15][16][17]
    • Spinal cord or cauda equina compression
    • Aortic dissection
    • Aortic aneurysm
    • Vertebral osteomyelitis
    • Epidural abscess
    • Metastatic cancer
  • The frequency of conditions exclusive of the above in a descending order is:
    • Vertebral compression fracture
    • Radiculopathy
    • Spinal stenosis
    • Ankylosing spondylitis
    • Osteoarthritis
    • Scoliosis
    • Hyperkyphosis
    • Psychologic distress
  • The frequency of conditions outside the spine exclusive of the above in a descending order is:
    • Piriformis syndrome
    • Sacroiliac joint dysfunction
    • Bertolotti's syndrome (Lumbosacral transitional vertebrae)

Differential Diagnosis of Back Pain:

When a patient presents with back pain, the following differentials mentioned in the table below need to be ruled out to reach the appropriate diagnosis.[18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53]

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell); Coronary CT angiography (CCTA); multidetector row scanners (MDCT); Cardiovascular magnetic resonance — CMRI; Myocardial perfusion imaging (MPI); single-photon emission CT (SPECT); Positron emission tomography (PET) scanning; Magnetic resonance (MR) angiography, Computed tomographic (CT) angiography, and Transesophageal echocardiography (TEE), late gadolinium enhancement (LGE); right ventricular hypertrophy (RVH), right atrial enlargement (RAE), functional tricuspid regurgitation (TR), Pulmonary artery systolic pressure (PASP; adenosine deaminase (ADA); Serum amyloid A (SAA), soluble interleukin-2 receptor (sIL2R); High-resolution CT (HRCT) scanning;

Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Stable Angina Sudden (acute) 2-10 minutes
  • Heaviness/pressure/ tightness/squeezing/ burning (Levine's sign)
  • Retrosternal or left sided chest pain
- - +/- - Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
  • Cardiac enzymes normal
  • Exercise EKG: ST-segment depression
  • Exercise Stress Testing: Decreased myocardial perfusion
  • Transthoracic echocardiography: Ejection fraction <50 percent
  • Coronary angiography
Unstable Angina Acute 10-20 minutes
  • Same as stable angina but often more severe
- - + - Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
  • ST-depression
  • New T wave inversions
  • Transient ST-elevation
  • Echocardiography: Ejection fraction <50 percent
  • Exercise Stress Testing: Decreased myocardial perfusion
  • Invasive coronary angiography
Myocardial Infarction[18][19][20][21] Acute Commonly > 20 minutes
  • Same as stable angina but often more severe
- - + - Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
  • Hypotension
  • Tachycardia
  • ST elevation MI (STEMI)
  • Non-ST elevation MI (NSTEMI) or Non Q wave
  • Echocardiography: ↓ EF
  • CCTA: Coronory artery stenosis
  • CMRI: Coronory vessels stenosis
  • MPI on SPECT or PET scanning: Decreased myocardial perfusion.
  • CCTA combined with MPI
Cardiac Vasospastic/ Prinzmetal/ Variant Angina Gradual in onset and offset Episodic, gradual in onset and offset. Chest discomfort described as squeezing, tightness, pressure, constriction, strangling, burning, heart burn, fullness in the chest, a band-like sensation, knot in the center of the chest, lump in the throat, ache, and heavy weight on chest - - + -
  • Nausea, sweating, dizziness, dyspnea, and palpitations
  • Associated with other vasospastic disorders, such as Raynaud's phenomenon and migraine headache
  • Multiple drugs (ephedrine-based products, cocaine, marijuana, alcohol, butane, sumatriptan, and amphetamines)
  • Food-born botulism
  • Guide wire or balloon dilatation while doing PCI
  • Magnesium deficiency
Tachycardia, hypertension, diaphoresis, and a gallop rhythm 
  • Urine drug screen may be positive for cocaine or other drugs
  • Transient (less than 15 minutes) ischemic ST changes in multiple leads
  • A tall and broad R wave,
  • Disappearance of the S wave
  • A taller T wave
  • Negative U waves
  • Stress testing: normal noninvasive stress test, exercise-induced spasm with ST-segment elevation,
  • Stress echocardiography with ergonovine provocation: Vasospasm of coronory vessels
  • Coronary arteriography: Epicardial spasm
  • Coronary arteriography
Aortic Dissection Sudden severe progressive pain (common) or chronic (rare) Variable
  • Tearing, ripping sensation, knife like
- - + -
  • Hypertension
  • Genetically mediated collagen disorders
  • Preexisting aortic aneurysm
  • Bicuspid aortic valve
  • Aortic coarctation
  • Turner syndrome
  • Vasculitis (giant cell arteritis, Takayasu arteritis, rheumatoid arthritis, syphilitic aortitis)
  • Nonspecific ST and T wave changes
  • CXR: Mediastinal and/or aortic widening
  • CTA: A compressed true lumen
  • MRA: Detects differential flow between the true and false lumens, widening of the aorta with a thickened wall
  • TEE: Intimal dissection flaps, true and false lumens, thrombosis in the false lumen
  • Aortography: Distortion of the normal contrast column, Flow reversal or stasis into a false channel, Failure of major branches to fill, and Aortic valvular regurgitation
  • CT angiography
  • Digital subtraction aortography (if high suspicion)
Pericarditis Acute or subacute May last for hours to days
  • Sharp & localized retrosternal pain
+ + + -
  • HIV
  • TB
  • Immunosuppression
  • Acute trauma
  • EKG changes (typically widespread ST segment elevation or PR depressions)
  • Chest x-ray typically normal
  • Echocardiogram: normal or pericardial effusion
  • CT scan: Noncalcified pericardial thickening with pericardial effusion
  • CMR: inflamed pericardium and myocarditis
  • Pericardiocentesis
  • Pericardial biopsy
Pericardial Tamponade Acute or subacute May last for hours to days
  • Sharp and stabbing retrosternal pain
+/- + + -
  • HIV
  • TB
  • Immunosuppression
  • Acute trauma
EKG findings:
  • Sinus tachycardia
  • Low QRS voltage
  • Electrical alternans
  • CXR: enlarged cardiac silhouette with clear lung fields
  • Echocardiography: Chamber collapse, Respiratory variation in volumes and flows, IVC plethora
  • Swan-Ganz Catheterization: Equilibration of average intracardiac diastolic pressures (usually between 10 and 30 mmHg) 
  • Echocardiography
Myocarditis Acute or subacute Variable
  • Sharp & localized retrosternal pain reflects associated pericarditis
+/- + + -
  • Heart failure
  • Sudden cardiac death
  • Arrythmias
  • S3 and S4 gallop
  • Cardiac murmurs
  • Pericardial friction rub
  • Serum cardiac troponin levels
  • ↑ BNP or NT-proBNP level 
Nonspecific ST changes, single atrial or ventricular ectopic beats, complex ventricular arrhythmias
  • CXR: Normal to enlarged with or without pulmonary vascular congestion and pleural effusions
  • Echo: Left ventricular dilation, changes in left ventricular geometry (eg, development of a more spheroid shape), and wall motion abnormalities
  • CMR: T1 and T2 signal intensity consistent with edema, presence of LGE consistent with necrosis or scar
  • Radionuclide ventriculography: ↓ EF
  • Cardiac catheterization: Assessment of hemodynamic status
Endomyocardial biopsy
Hypertrophic cardiomyopathy Acute or subacute Variable Typical or atypical chest pain - - -
  • HF
  • Arrhythmias
  • Syncope
  • Acute hemodynamic collapse 
  • S4
  • Systolic murmurs
  •  LV apical impulse
  • Brisk carotid pulse
  • ↑ JVP
  • A parasternal lift
Non-specific
  • Prominent abnormal Q waves
  • P wave abnormalities
  • Left axis deviation
  • Deeply inverted T waves
-Echocardiography:
  • LV hypertrophy
  • Systolic anterior motion of the mitral valve,
  • LVOT obstruction 

- Cardiac catheterization

  • Pressure gradient
  • Augmentation of the gradient
  • Aortic pressure
  • Left ventricular pressure
  • Left atrial or pulmonary capillary wedge pressure

-Coronary angiography

  • Obstructive epicardial coronary artery disease

- Genetic testing for HCM

Stress (takotsubo)

Cardiomyopathy

Acute Commonly > 20 minutes
  • Substernal heaviness or tightness
- - + -
  • Setting of physical or emotional stress or critical illness
Stress
  • ST segment elevation
  • ST depression
  • QT interval prolongation, T wave inversion, abnormal Q waves
  • Radionuclide myocardial perfusion imaging: Transient perfusion abnormalities in the left ventricular apex
  • Ventriculography and invasive coronary angiography
Aortic Stenosis Acute, recurrent episodes of angina 2-10 minutes
  • Heaviness/pressure/ tightness/squeezing/ burning (Levine's sign)
  • Retrosternal
- - + -
  • HTN
  • Old age
  • Schistiocytes on peripheral blood smear
  • Non specific (the voltage of the QRS complex is increased showing the presence of left ventricular hypertrophy)
  • Echocardiography: aortic leaflets thickened and calcified, ↑ pulmonary artery pressure)
  • CMR: Myocardial fibrosis, evaluation of aortic anatomy and size
  • MDCT: Degree of aortic valve calcification
  • PET: Measures active mineralization which correlates with stenosis severity
    • Echocardiography
Heart Failure Subacute or chronic Variable
  • Dull
  • Left sided chest pain
+ - + + Dyslipidemia, hypertension, smoking, family history of premature disease, and diabetes
  • EKG findings are specific according to each cause of heart failure
  • Q waves, ST and T wave abnormalities in patients with prior MI
  • New onset arrhythmias (atrial fibrillation and ventricular tachycardia)
  • CXR: Cardiomegaly
  • Echocardiography: ↓ EF
  • Right heart catheterization: Pulmonary capillary wedge pressure >20 mmHg, right atrial pressure ≥12 mmHg) and/or decreased cardiac index (≤2.2 L/min/m2
  • Echocardiography
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Pulmonary Pulmonary Embolism Acute May last minutes to hours
  • Sharp or knifelike or pleuritic pain
  • Localized to side of lesion
+ +/- + -  Hormone replacement therapy

 Cancer

 Oral contraceptive pills

  Stroke 

Pregnancy

  Postpartum 

Prior history of VTE

  Thrombophilia 

  • Tachycardia and nonspecific ST-segment and T-wave changes (70 percent)
  • S1Q3T3 pattern
  • New right bundle branch block
  • Inferior Q-waves (leads II, III, and aVF)
  • CT pulmonary angiography
Spontaneous Pneumothorax Acute May last minutes to hours
  • Sharp
  • Localized pleuritic
- - + -
  • Smoking
  • Positive family history
  • Marfan syndrome
  • Homocystinuria
  • Thoracic endometriosis.
  • Respiratory alkalosis on ABGs
  • Rightward shift in the mean electrical axis
  • Loss of precordial R waves
  • Diminution of the QRS voltage
  • Precordial T wave inversions
  • CXR: White visceral pleural line on the chest radiograph
  • CT: small amounts of intrapleural gas, atypical collections of pleural gas, and loculated pneumothoraces
  • CT scan
Tension Pneumothorax Acute May last minutes to hours
  • Sharp
  • Pleuritic
- - + - Trauma
  • Significant elevation of the ST-T segment from leads V1 to V4
  • CXR: A distinct shift of the mediastinum to the contralateral side, collapse of the ipsilateral lung, and flattening or inversion of the ipsilateral hemidiaphragm
  • CT scan
Pneumonia Acute or chronic Variable
  • Dull
  • Localized to side of lesion
+ + + +/-
  • Sinus tachycardia
  • Nonspecific ST-segment or T-wave changes
  • CXR: Interstitial infiltrates, lobar consolidation, cavitation 
  • CXR
Tracheitis/ Bronchitis Acute Variable
  • Dull
  • Substernal
+ + + -
  • Inspiratory stridor (with or without expiratory stridor)
  • Nasal flaring
  • Wheezing
  • Gram stain of exudates: Neutrophils
  • Peaked P-wave
  • Radiography of the neck: Steeple sign
  • Laryngotracheobronchoscopy: a normal epiglottis with subglottic narrowing, thick and purulent secretions in the trachea, pseudomembranes
  • Endoscopy
Pleuritis Acute or subacute or chronic May last minutes to hours
  • Sharp
  • Localized pleuritic
+ + + -
  • Autoimmune conditions
  • Infections
  • Tachypnea
  • Tachycardia 
  • EKG done to rule out other causes in differential diagnoses
  • Chest X Ray: Pleural fluid on one or both sides
  • Computerized tomography (CT) scan: Pleural effusions
  • CXR
Pulmonary Hypertension Acute or subacute or chronic Variable
  • Substernal pressure like
+ - + -
  • Right axis deviation
  • An R wave/S wave ratio greater than one in lead V1
  • Incomplete or complete right bundle branch block
  • Increased P wave amplitude in lead II (P pulmonale) due to right atrial enlargement 
  • Chest Radiography: Oligemic lung fields 
  • Echocardiography: PASP is >50 and the TRV is >3.4
  • Ventilation-Perfusion (V/Q) Lung Scanning: Abnormal
  • Right-sided cardiac catheterization: Mean PCWP >15 mmHg,
  • Cardiac catheterization
Pleural Effusion Acute or subacute or chronic Variable
  • Dull
  • Pleuritic pain
+ +/- + +/-
  • Typically not indicated
  • Chest X Ray: Pleural fluid on one or both sides
  • Computerized tomography (CT) scan: Detects small pleural effusions, ie, less than 10 mL and possibly as little as 2 mL of liquid in the pleural space, Thickening of the visceral and parietal pleura 
  • MRI: Characterize the content of pleural effusions
  • Computed tomography
Asthma & COPD Acute or subacute or chronic Variable
  • Tightness
+ +/- + +/-
  • Smoking
  • HF
  • HTN
  • Leukocytosis
  • Eosinophilia
  • Respiratory alkalosis
  • Peaked P-wave
  • Reduced amplitude of the QRS complexes
  • Multifocal atrial tachycardia (MAT)
  • Spirometry
Pulmonary Malignancy Chronic Variable
  • Dull aching
+ +/- + +
  • Smoking
  • Metastasis
  • Wheeze
  • Crackles
  • EKG may be performed before cancer treatment to identify any pre-existing conditions, or during treatment to check for possible heart damage
Sarcoidosis Chronic Days to week
  • Chest fullness
+ - + +
  • Diminished respiratory sounds
  • ↑ ACE level, adenosine deaminase, SAA, sIL2R
  • Hypercalciuria
  • Elevated 1,25-dihydroxyvitamin D levels
  • AV block
  • Prolongation of the PR interval (first-degree AV block)
  • Ventricular arrhythmias (sustained or nonsustained ventricular tachycardia and ventricular premature beats [VPBs]) 
  • Supraventricular arrhythmias
  • Chest radiograph: Bilateral hilar adenopathy,
  • High-resolution CT (HRCT) scanning of the chest: Ground glass opacification, Hilar and mediastinal lymphadenopathy, Bronchial wall thickening
  • Lung Biopsy
Acute chest syndrome (Sickle cell anemia) Acute May last minutes to hours
  • Chest tightness
+ +/- + -
  • ↑ WBC
  • ↑ Hb levels
  • ↓ fetal hemoglobin levels
  • Smoking
  • Vaso-occlusive pain events
  • EKG typically not indicated
  • Plain radiography of the extremities: Avascular necrosis
---
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab Findings EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Gastrointestinal GERD, Peptic Ulcer Acute +/- - - +/-
  • Prolonged NSAIDs intake
  • Smoking
  • Alcohol abuse
  • Spicy foods
  • H-pylori
  • Not any auscultatory findings associated with this disease
  • Enamel erosion or other dental manifestations
  • ↑Serum Gastrin Level
  • Secretin Stimulation Test
  • H-Pylori testing
  • EKG usually normal but may show T wave inversions in leads V2 through V4 consistent with myocardial ischemia in patients with peptic ulcer perforation
  • Upper Gastrointestinal Endoscopy: Biopsy
  • Esophageal Manometry: To exclude an esophageal motility disorder
  • Esophageal impedance pH testing: Monitors esophageal pH
  • Upper Gastrointestinal Endoscopy
Diffuse Esophageal Spasm Acute
  • Minutes to hours
  • 5 to 60 minutes
  • Burning
  • Pressure
  • Visceral, spontaneous, substernal,
+ - +/- +/-
  • Associated with cold liquids
  • Relief with nitroglycerin
--- ---
  • Barium swallow: Multiple areas of spasm throughout the length of the esophagus
  • Impedance testing: Higher amplitudes and better transit of swallowed boluses
  • No ECG findings associated with DES, but ECG is done to exclude variant angina due to higher concurrent association of variant angina with DES 
  • Esophageal manometry : ≥20 percent premature contractions (distal latency <4.5 seconds)
  • Esophageal manometry
Esophagitis Acute Variable + + - +/-
  • HIV
  • Immunosuppression
  • No auscultatory finding
  • ECG is done to rule out acute coronary syndrome
  • Double-contrast esophageal barium study (esophagography)
  • Endoscopy: Biopsy
  • Endoscopy
Eosinophilic Esophagitis Chronic Variable
  • Burning
  • Retrosternal
  • Abdominal
+ - - -
  • Dysphagia
  • Food impaction
  • GERD
  • No auscultatory finding in the this disease
  • Elevated IgE (>114,000 units/L)
  • Elevated peripheral eosinophils
  • Typically no finding on EKG
  • Barium studies: Strictures and a ringed esophagus
  • Endoscopy: Stacked circular rings ("feline" esophagus) ●Strictures ●Linear furrows ●Whitish papules 
  • Esophageal biopsy: More than 15 eosinophils per high-power field
  • Esophageal biopsy
Esophageal Perforation[23] Acute Minutes to hours
  • Burning
  • Upper abdominal
- +/- + -
  • Instrumentation/surgery
  • Penetrating or blunt trauma
  • Medications, other ingestions, foreign body
  • Violent retching/vomiting
  • Hernia/intestinal volvulus/obstruction
  • Inflammatory bowel disease
  • Appendicitis
  • Peptic ulcer disease
  • ↑Serum amylase
  • ↑C-reactive protein levels
  • Plain chest films or chest CT: Pneumomediastinum, Free air under the diaphragm, •Pleural effusion •Pneumothorax (Macklin effect).   •Subcutaneous emphysema
  • Plain abdominal films (or abdominal CT scout film):The appearance of pneumoperitoneum -Free air under the diaphragm -Cupola sign (inverted cup) -Rigler sign (double-wall sign) -Psoas sign -Urachus sign 
    • Confirmed by water-soluble contrast esophagram
Mediastinitis Acute, Chronic Variable
  • Retrosternal irritation
+/- + + -
  • Nonspecific
  • Infection
  • Esophageal perforation
  • Post operative complication
  • Positive organisms in sternal culture
  • Leukocytosis
  • Positive blood cultures
  • Diffuse ST elevation
  • CT: Localize the infection and extent of spread
  • MRI: Assesses vascular involvement and complications
CT scan
 Cholelithiasis Acute, subacute Minutes to hours - +/- - - The presence of a common bile duct stone on transabdominal ultrasound

•Clinical acute cholangitis

•A serum bilirubin greater than 4 mg/dL (68 micromol/L)

  • Murphy sign negative
  • Jaundice
  • ↑ALT
  • ↑AST
  • Amylase levels
  • ↑ALP
  • Typically not indicated
  • Transabdominal ultrasound (TAUS): shows gallstones
  • EUS: Detects biliary sludge
  • MRCP: Detects stones >6mm
  • Endoscopic Retrograde Cholangiopancreatography (ERCP): Diagnostic and therapeutic removal of stones
Endoscopic ultrasound and MECP
Pancreatitis Acute, Chronic Variable - + + +/-
  • Alcohol abuse
  • Smoking
  • Genetic predisposition
  •  Tachypnea
  • Hypoxemia
  • Hypotension
  • Cullen's sign
  • Grey Turner sign 
  • T-wave inversion
  • ST-segment depression
  •  ST-segment elevation rarely
  • Q-waves
  • CT: focal or diffuse enlargement of the pancreas
  • MRI: Pancreatic enlargement
  • CT Scan
Sliding Hiatal Hernia Acute Variable + - + -
  • Trauma
  • Iatrogenic
  • Congenital malformation
  • Bowel sounds may be heard in the chest
  • Non specific
  • T wave inversion in anterior lead.
  • Barium swallow: At least three rugal folds traversing the diaphragm 
  • Upper endoscopy: A greater than 2-cm separation between the squamocolumnar junction and the diaphragmatic impression
  • High resolution manometry: The separation of the crural diaphragm from the lower esophageal sphincter (LES) by a pressure trough
  • Upper endoscopy
  • High resolution manometry (for smaller hernias)
Musculoskeletal Costosternal syndromes (costochondritis) Acute, subacute Days to weeks
  • Pressure like on anterior part of chest wall
- + - -
  • History of repeated minor trauma or unaccustomed activity (eg, painting, moving furniture) 
  • Trauma
  • Pain by palpation of tender areas
  • Maneuvers, such as the "crowing rooster" and horizontal arm flexion maneuver
  • Non specific
  • EKG is done to rule out other cardiovascular causes
  • CXR: To rule out fracture
Pain by palpation of tender areas
Lower rib pain syndromes Chronic Variable
  • Aching
  • Lower chest
  • Upper abdomen
- - + -
  • Common in women with a mean age in the mid-40s
---
  • Hooking maneuver
  • Reproduces pain by pressing a tender spot on the costal margin
  • Non specific
  • The workup is done for excluding cardiac disorders and other causes of chest pain
  • EKG is done to rule out other cardiovascular causes
  • CXR: To rule out fracture
---
Sternalis syndrome Chronic Variable Pressure like pain
  • Over the body of sternum
  • Sternalis muscle
  • Left or middle side of the chest wall
- - - -
  • Localized tenderness is found directly over the body of the sternum or overlying sternalis muscle
  • No specific diagnostic test for this disease
  • The workup is done for excluding cardiac disorders and other causes of chest pain
  • EKG is done to rule out other cardiovascular causes
  • X-ray : To rule out fracture
Physical exam
Tietze's syndrome Acute Weeks Pressure like pain over - - - -
  • Most often involve the areas of 2nd and 3rd ribs
  • More common in young adults
  • Sternocostoclavicular hyperostosis
  • Ankylosing spondylitis
  • Upper respiratory infections
  • Excessive coughing
  • No specific diagnostic test for this disease
  • The workup is done for excluding cardiac disorders and other causes of chest pain
  • EKG is done to rule out other cardiovascular causes
  • X-ray: To rule out fracture
  • Tests are done to rule out other diseases
Xiphoidalgia Acute Variable Pressure like pain over
  • Over the xiphoid process
  • Sternum
  • Xiphisternal joint
- - - -
  • Symptoms are aggravated by twisting and bending movements
  • Cough
  • Heavy work
  • Provocative test
  • No specific diagnostic test for this disease
  • The workup is done for excluding cardiac disorders and other causes of chest pain
  • EKG is done to rule out other cardiovascular causes
  • X-ray: To rule out fracture
  • Tests are done to rule out other diseases
Spontaneous sternoclavicular subluxation Acute, Chronic Variable Aching pain over Sternoclavicular joint - - - -
  • More common in middle age women
  • Occurs in dominant hands with repetitive tasks of heavy or moderate quality
  • Trauma
  • No specific diagnostic test for this disease
  • The workup is done for excluding cardiac disorders and other causes of chest pain
  • EKG is done to rule out other cardiovascular causes
  • X-ray: Sclerosis of the medial clavicle 
  • X-ray
Differentials on the basis of Etiology Disease Clinical manifestations Diagnosis
Symptoms Risk factors Physical exam Lab workup EKG Imaging Gold standard
Onset Duration Quality of Pain Cough Fever Dyspnea Weight loss Associated Features
Rheumatic Fibromyalgia Chronic Variable - - + - ---
  • Presence of tenderness in soft-tissue anatomic locations
  • Non specific
  • Normal Blood and urine test (mandatory to rule out other diseases)
  • P-wave dispersions (Pd)
--- ---
Rheumatoid arthritis Chronic Years Symmetrical joint pain in
  • Wrist
  • Fingers
  • Knees
  • Feet
  • Ankles
- + - +
  • Old age
  • Smoking
  • Autoimmune conditions
  • Positive Rheumatic Factor
  • Anti-CCP body 
  • Synovial fluid analysis: WBC between 1500 and 25,000/cubicmm, low glucose, low C3 and C4 complement level.
  • Thrombocytosis
  • Anemia
  • Mild leukocytosis
  • ECG is done rule out the heart failure as RA is one of the causes of heart failure
  • Plain film radiography: periarticular osteopenia, joint space narrowing, and bone erosions
  • MRI: Bone erosions
  • Ultrasonography: Degree of inflammation and the volume of inflamed tissue
---
Ankylosing spondylitis Chronic Years Intermittent pain in - - - -
  • ECG is done to rule out conductions defects and aortic insufficiency
  • Computed tomography (CT)
  • Magnetic resonance imaging (MRI)
  • Power Doppler ultrasonography
  • Plain films of the sacroiliac joints
Psoriatic arthritis Chronic Years Asymmetrical intermittent pain in - - - -
  • Serum complement
  • Levels of Long Prentaxin 3 protein (PTX3)
  • Increased levels of CRP
  • Erythrocyte sedimentation rate
  • Rheumatoid factor
  • Immunoglobulin
  • Longer PR interval 
  • X-ray of the involved joints
  • CT scanning
  • MRI
  • Ultrasonography
  • No any gold standard test is available for this test
Sternocostoclavicular hyperostosis (SAPHO syndrome) Chronic Years Recurrent and multifocal pain in

Sternoclavicular joint

- + - -
  • Depending on the type of joint affected
  • ECG is done to rule out conductions defects and aortic insufficiency
  • Plain radiography
  • Computed tomography
  • Bone scan
  • Magnetic resonance imaging
  • Positron emission tomography
  • No any gold standard test is available for this disease
Systemic lupus erythematosus  Chronic Years
  • Skin
  • Joints (fingers, wrist, knees)
  • Kidneys
  • SLE can affect any organ of the body
- + + +
  • HLA-genetic mutations
  • Female gender
  • Being younger than 50 
  • Joint radiography
  • Chest X-ray
  • CT Scan
  • MRI
  • Echocardiography
  • Arthrocentesis
  • Lumbar puncture
  • Anti-dsDNA antibody test
Relapsing polychondritis Chronic Years Intermittent pain in + + + +
  • Negative rheumatoid factor
  • Biopsy
  • Complete blood cell count (CBC) with differential
  • Metabolic panel
  • Serum creatinine
  • Liver transaminase and serum alkaline phosphatase studies
  • Urinalysis dipstick and microscopic evaluation of sediment
  • Cryoglobulins
  • Viral hepatitis panel
  • Antinuclear antibody (ANA)
  • Antineutrophil cytoplasmic antibody (ANCA)
  • ECG is done to rule out the cardiovascular complications of this disease
  • Chest radiography
  • Spiral CT scanning
  • FDG-PET/CT
  • MRI
  • Posteroanterior and lateral dye contrast pharyngotracheogram
  • Scintigraphy
  • No gold standard test for this disease
Psychiatric Panic attack/ Disorder Acute or subacute or chronic Variable Variable + - + -
  • Anxious
  • Tachypneic
  • Thyroid function tests
  • Complete blood count
  • Chemistry panel
  • Sinus Tachycardia
  • No any specific radiographic test is done
  • No gold standard test for panic attack
Others Substance abuse

(Cocaine)

Acute (hours) Minutes to hours Pressure like pain in the center of chest + + + +
    • QT prolongation
    • Sinus Tachycardia
    • Arrhythmias
    • Cardiac conduction abnormalities
  • Brain CT scan
  • Gold standard test depends on the type of substance is abuse
Herpes Zoster Acute or Chronic Variable Burning pain on
  • Chest
  • Upper back
  • Lower back
- + - -
  • ECG is done to rule out other cardiovascular causes of chest pain
  • Magnetic resonance imaging (MRI)
  • Viral tissue culture


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