Thoracic/back

Back Pain

Rapid Review

  • Differentials
    • “CRAFTI”
      • Compression
        • Cauda equina
        • Conus medullaris
        • Epidural hematoma
      • Renal stone 
      • Aortic aneurysm/dissection
      • Fracture
      • Tumor
      • Infection/Inflammatory
        • Pyelonephritis
        • Perinephric abscess
        • Epidural abscess
        • Osteomyelitis
        • Discitis
        • Transverse myelitis
    • Other common causes
      • Mechanical low back pain
      • Sciatica/Radiculopathy
  • History
    • Recent injury
      • Consider fracture, strain
    • Recent unintentional weight loss
      • Consider malignancy
    • IV drug use
      • Consider epidural abscess
    • Syncopal episode
      • Consider aortic dissection, aneurysm
    • Urinary incontinence or saddle anesthesia
      • Consider cauda equina
    • Fever/chills
      • Consider infectious process
  • Physical Exam
    • Spinal tenderness. Step-off deformity.
      • Consider fracture
    • CVA tenderness
      • Consider nephrolithiasis or pyelonephritis
    • Sphincter dysfunction
      • Consider cauda equina
  • Work-Up
    • Labs
      • CBC, BMP, ESR, CRP
      • Urinalysis
      • Beta-hCG
      • Post-Void Residual
    • Imaging
      • X-ray (spinal)
      • CT Spine (non-contrast)

Pearls

  • Always visually examine the area of pain. You do not want to miss a dermatological condition! (ex. shingles, cellulitis)
  • Imaging is typically low yield in patients with uncomplicated mechanical low back pain. Reserve imaging for significant trauma or suspected renal, vascular, or infectious pathology. 

Deep Dive

Video Credit: The Center for Medical Education

Chest Pain

Rapid Review

  • Differentials
    • Cardiovascular
      • Acute coronary syndrome
      • Aortic dissection
      • Pericarditis
    • Pulmonary
      • Pulmonary embolism
      • Pneumothorax
      • Pneumonia
    • Gastrointestinal
      • Boerhaave’s Syndrome
      • Pneumomediastinum
      • Gastroesophageal Reflux (GERD)
    • Thoracic Wall
      • Costochondritis
      • Rib contusion/fracture
      • Shingles
    • Psychiatric
      • Anxiety/Panic attack
  • History
    • Ripping/tearing pain
      • Consider aortic dissection
    • Exertional
      • Consider ACS, heart failure
    • Pleuritic
      • Consider PE, pericarditis, pneumonia
    • Positional
      • Consider pericarditis or myocarditis
    • Estrogen use
      • Consider PE
    • Hx of HTN, HLD, DM, or PVD
      • Consider ACS
    • Prior cardiac procedures (stents, bypass, echo, catheterization, etc.)
      • Consider ACS or surgical complications
    • History of anxiety
      • Consider panic attack
    • Fever/Chills
      • Consider pneumonia or other infectious causes
  • Physical Exam
    • JVD
      • Suggests right-sided HF
    • New murmurs
      • Consider valvular dysfunction
    • Abnormal lung sounds (rales, rhonchi, wheezing)
      • Consider pneumonia, CHF exacerbation, etc.
    • Chest wall tenderness
      • Consider costochondritis, pericarditis
    • Edema
      • Consider heart failure
  • Work-Up
    • EKG
      • Look for bradycardia, tachycardia, ST-segment elevation/depression,
    • Labs
      • CBC, BMP
      • Troponin
      • D-Dimer
    • Imaging
      • CXR
      • CT PE (if concern for pulmonary embolism)
      • CT aortogram (if concern for aortic dissection
      • Echocardiogram (if concern for pericardial effusion)

Pearls

  • Serial EKGs (often every 15-30 minutes) should be done in patients who have symptoms that are highly suspicous for ACS. Do not wait for a troponin to come back. 
  • The HEART score can help make disposition decisions for patients with suspected ACS. 

Deep Dive

Video Credit: Anna Pickens

Palpitations

Rapid Review

  • Differentials
    • Arrhythmias
      • Sinus tachycardia
      • AVRT/AVnRT
      • Atrial flutter
      • Atrial fibrillation
      • Multifocal Atrial Tachycardia
      • Ventricular Tachycardia
      • PVC’s or PAC’s
    • Valvular Disease
      • Mitral or aortic insufficiency
      • Mitral valve prolapse
    • Psychiatric
      • Panic attack
      • Anxiety
      • Somatization
      • Depression
    • Drug/Medication Use
      • Caffeine
      • Amphetamines
      • Cocaine
      • Aspirin overdose
      • Alcohol/Opiate withdrawal
    • Other
      • ThyrotoxicosisAnemia
      • Addisonian Crisis
      • Carcinoid Syndrome
  • History
    • Recent ingestion of substance
      • Consider caffeine, amphetamines, or alcohol
    • Recent stressors
      • Consider anxiety, depression, panic disorder
    • Associated with chest pain/SOB on exertion
      • Consider ACS, CHF, valvular disorders
  • Physical Exam
    • Murmurs
      • Consider valvular dysfunction
    • JVD
      • Consider heart failure
    • Irregularly irregular heart rate
      • Consider atrial fibrillation/flutter
  • Work-Up
    • EKG
    • Labs
      • CBC, BMP
      • Troponin
      • TSH + Free T4
      • Urine drug screen
      • Pregnancy test

Pearls

  • Take a careful history to try to identify triggers to the palpitations (ex. caffeine, drugs, alcohol, exertion, stressful situations, etc.) This can help guide your work-up.
  • Many patients who have negative work-ups in the ED may require outpatient cardiology referral for holter monitoring. 
Video Credit: Strong Medicine

Shortness of Breath

Rapid Review

  • Differentials
    • Airway
      • Airway obstruction
      • Anaphylaxis
      • Abscess or tumor
    • Breathing
      • Asthma
      • Pulmonary embolism
      • COPD exacerbation
      • Pleural effusion
      • Noncardiogenic edema
      • Pneumothorax
      • Pneumonia
    • Cardiac
      • Congestive heart failure
      • Pericardial effusion/Cardiac tamponade
      • Acute Coronary Syndrome
      • Arrhythmia
      • Valvular dysfunction
    • Other
      • Anemia
      • Anxiety/Panic attack
      • Trauma (pulmonary contusion/flail chest)
      • Diabetic Ketoacidosis
      • CO poisoning
  • History
    • Exertional
      • Suggests ACS, HF, or PE
    • History of previous lung disorders
      • Consider COPD, Asthma
    • Hx of diabetes
      • Consider DKA
    • History of cardiac disorders
      • Consider ACS, HF, valvular problems
    • Recent trauma
      • Consider pneumothorax, pulmonary contusion
    • Recent travel/immobilization. Estrogen use
      • Consider pulmonary embolism
    • Fever/chills
      • Consider infectious causes
  • Physical Exam
    • Apparent distress or tripod positioning
      • Consider need for urgent airway/breathing management
    • Murmurs, rubs, gallops
      • Consider HF, pericarditis
    • JVD
      • Consider right-sided HF
    • Abnormal lung sounds (rales, rhonchi, wheezing)
      • Consider HF, asthma, COPD, pneumonia
  • Work-Up
    • EKG
    • Labs
      • CBC, BMP, troponin, d-dimer, BNP
    • Imaging
      • CT PE (if considering pulmonary embolism)
      • Echo (if suspect effusion, HF)

Pearls

  • Point of care ultrasound can rapidly evaluate for several different etiologies of SOB (pulmonary edema, pneumothorax, pneumonia, pericardial effusion, etc.)
  • Be careful not to anchor to one etiology of dyspnea based on the patients medical history. Patients with asthma can have pulmonary embolisms too!
Video Credit: Strong Medicine