Thoracic red flags

What are the non-MSK pathologies that likely require referral?

• cardiac: MI, angina, pericarditis, thoracic aortic aneurysm

• pulmonary: PE, lung cancer, pneumonia

• GI: GERD, gastric ulcer, pancreatitis

• hepatobiliary: hepatitis, cholecystitis

• spleen: splenomegaly

• integumentary: herpes zoster

Where are the most common pain referral sites for thoracic aortic aneurysm?

• chest/sternum

• neck

• left shoulder

• BIL medial arm

• upper back

What are the risk factors for thoracic aortic aneurysm?

• family hx

• obesity

• stress

• CT diseases

• sedentary

• smoking

What are the common Sx’s for thoracic aortic aneurysm?

• aggravated by CV exertion, emotional stress

• deep pressure, throbbing, burning

• lightheadedness, dizziness, syncope

• SOB

• palpitations

• diaphoresis

• fatigue

• Sx’s at rest

What are the common exam findings for thoracic aortic aneurysm?

• high/low BP

• low SpO2

• tachy/bradycardia, irregular

• tachypnea

• reduced or absent pulses

• cyanosis

• clubbing

• pallor

• LE edema

• diaphoresis

List the clinical predictors for CAD from the INTERCHEST Rule.

What are the risk groups?

• men ≥55 or women ≥65

• physician initially suspected a serious condition

• chest discomfort feels like pressure

• chest pain related to effort

• hx of CAD

• pain reproduce by palpitating chest wall (-1)

• low risk = -1-0

• moderate risk = 1-2

• high risk = 3+

Where are the most common pain referral sites for lung pathologies?

• R shoulder

• R armpit/chest/upper back

What are the risk factors for lung pathologies?

• smoking

• family hx

• exposure to asbestos, coal, dust, chemicals

• PE risk factors

List the clinical characteristics for risk of PE.

What should you do if score ≥2? What would you recommend for pts?

• active cancer

• recent surgery or immobilization (within 4 weeks)

• hemoptysis

• HR >100 bpm

• alternative Dx less likely than PE

• previous PE/DVT

• signs of DVT

refer —> D-dimer, CT w/ angiography

What are the common Sx’s for lung pathologies?

• difficulty breathing

• aggravated by CV exertion

• orthopnea

• SOB

• coughing, wheezing, hemoptysis

• fatigue

• diaphoresis

What are the common exam findings for lung pathologies?

• high/low BP

• low SpO2

• tachy/bradycardia, irregular

• tachypnea

• cyanosis

• clubbing

• pallor

• LE edema

• diaphoresis

What are some other decision tools you can use to refer out a pt w/ a potential lung pathology?

Refer immediately if:

• unexplained hemoptysis

• weight loss >10 lbs within 2 months

• new onset SOB

Refer within 2 weeks if:

• age >40 w/ at least 2 of the following, or smoker w/ 1 of the folliwng:

  • coughing

  • fatigue

  • SOB

  • chest pain

  • weight/appetite loss

Annual low-dose CT test if ages 55-80, with:

• smoke 1 pack/day for 30 years or 2 packs/day for 15 years

• currently smoke or have quit within the last 15 years

Where are the most common pain referral sites for GI pathologies?

• esophagus: across chest, neck

• stomach: chest

• pancreas: chest

What are the risk factors for peptic ulcer disease?

• chronic NSAID or aspirin use with:

  • H pylori bacteria

  • older age

• excessive drinking

What are the common Sx’s for GI pathologies?

• regurgitation

• sour taste in mouth

• bloating

• nausea, vomiting

• night or morning pain when GI is empty

• loss of appetite, weight

• aggravated by lying down

• alleviated by upright position, antacids

• fatigue

• change in stool color, constipation, diarrhea

• lightheadedness, headache, confusion

• colic-like pain during rest

• gnawing, heartburn, sharp

What are the common exam findings for GI pathologies?

• masses or TTP

• low BP

• tachycardia

• jaundice

Where are the most common pain referral sites for hepatobiliary pathologies?

• R upper abs

• R shoulder

What are the risk factors for hepatobiliary pathologies?

• family hx

• IV drug use (hepatitis)

• drinking (liver)

What are the common Sx’s for hepatobiliary pathologies?

• nausea, vomiting

• intolerance to fatty foods

• excruciating pain acutely

What are the common exam findings for hepatobiliary pathologies?

• confusion

• ascites, LE edema

• jaundice

• Murphy’s sign

What are the risk factors for spleen pathologies?

• recent trauma

• recent infection (mononucleosis)

What are the common Sx’s & exam findings for spleen pathologies?

• fever, malaise, fatigue, chills

• pain in L upper quadrant or L shoulder

• TTP

What are the common Sx’s & exam findings for herpes zoster/Shingles?

• pain, itchiness, tingling in area of rash

• unilateral pain along dermatome or CN

• hyperalgesia, allodynia along dermatome or CN

• rash w/ vesicles in dermatomal or CN pattern