Chest pain can be a symptom of a number of severe conditions and is generally considered a medical emergency. Although it is clear that pain is non-cardiac origin, which is often a diagnosis of exclusion after excluding the most serious causes of pain.
SYMPTOMS AND SIGNS ACCORDING TO LIKELY ETIOLOGY
COSTOCHONDRAL OR CHEST WALL PAIN
Localized sharp/stabbing or persistent/dull pain ,reproduced by pressure over the painful area.
CERVICAL OR THORACIC SPINE DISEASE WITH NERVE ROOT COMPRESSION
Sharp pain,may be in radicular distribution ,exacerbated by movement of neck,back.
ESOPHAGEAL OR GASTRIC PAIN
Associated with dysphagia or gastric regurgitation,may be worsened by aspirin/alcohol ingestion/certain foods/supine position: often relieved by antacids.
BILIARY PAIN
Intolerance of fatty foods, right upper quadrant tenderness also present.
MYOCARDIAL ISCHEMIA
Precipitated by exertion or emotional arousal .ECG ( or holter monitor ) during pain shows ST segment shifts ,pain relieved quickly ( < 5 minutes ) by sublingual TNG
DIFFERENTIAL DIAGNOSIS OF ACUTE CHEST PAIN
1.
*DESCRIPTION OF PAIN
Oppressive,constrictive ,or squeezing ,may radiate to arms ,neck and back.
*BACKGROUND HISTORY
Less severe ,similar pain on exertion plus coronary risk factors.
*KEY PHYSICAL FINDINGS
Diaphoresis ,pallor S4 common .S3 less common.
*CONSIDER
Acute Myocardial Infarction.
*CONFIRMATORY TESTS
Serial ECGs ,Serial cardiac markers ( especially troponin ,CK )
2.
*DESCRIPTION OF PAIN
tearing or ripping may travel from anterior chest to mid back.
*BACKGROUND HISTORY
Hypertension or Marfan syndrome.
*KEY PHYSICAL FINDINGS
Weak,asymptomatic peripheral pulses ,possible diastoic murmur or aortic insufficiency.
*CONSIDER
Aortic Dissection
*CONFIRMATORY TESTS
CXR -Widened mediastinal silhoutte ,MRI .CT ,or transesophageal echogram ,intimal flap visualized.Aortic angiogram ,definitive diagnosis.
3.
*DESCRIPTION OF PAIN
Crushing ,sharp ,pleuritic ,relieved by sitting forward.
*BACKGROUND HISTORY
recent upper respiratory tract infection ,or other conditions which predispose to pericarditis.
*KEY PHYSICAL FINDINGS
Pericardial friction rub ( usually 3 component best heard by sitting patient forward )
*CONSIDER
Acute pericarditis
*CONFIRMATORY TESTS
ECG ,diffuse ST elevation and PR segment depression. Echogram ,pericardial effusion often visualized.
4.
*DESCRIPTION OF PAIN
Pleuritic ,sharp possibly accompanied by cough /hemoptysis
*BACKGROUND HISTORY
Recent surgery or other immobilization
*KEY PHYSICAL FINDINGS
Tachypnea ,possible pleural friction rub.
*CONSIDER
Pulmonary Embolism
*CONFIRMATORY TESTS
Arterial blood gas ,hypoxemia and respiratoy alkalosis ,Lung scan ,V/Q mismatch ,pulmonary angiogram ,arterial luminal filling defects.
5.
*DESCRIPTION OF PAIN
Very sharp, pleuritic
*BACKGROUND HISTORY
recent chest ,or history of chronic obstructive lung disease.
*KEY PHYSICAL FINDINGS
tachypnea ,breath sounds and hyperesonance over affected lung field
*CONSIDER
Acute Pneumothorax
*CONFIRMATORY TESTS
CXR ,radioluency within pleural space poss ,collapse of adjacent lung segment , If tension pneumothorax mediastinum is shifted to opposite side.
6.
*DESCRIPTION OF PAIN
Intense substernal and epigastric accompanied by vomiting and/or hemoptysis.
*BACKGROUND HISTORY
Recent recurrent vomiting /retching
*KEY PHYSICAL FINDINGS
Subcutaneous emphysema ,audible crepitus adjacent to the sternum.
*CONSIDER
Rupture of esophagus
*CONFIRMATORY TESTS
CXR pneumomediastinum .Esophageal endoscopy is diagnostic
DIFFERENTIAL DIAGNOSIS OF PATIENTS ADMITTED TO HOSPITAL WITH ACUTE CHEST PAIN RULED NOT MYOCARDIAL INFARCTION
Gastroesophageal Disease 42%
*Gastroesophageal reflux
*esophageal motility disorders
*Peptic ulcer
*Gallstones
Ischemic Heart Disease 31%
Chest Wall Syndrome 28%
Pericarditis 4%
Pleuritic/pneumonia 2%
Pulmonary embolism 2%
Lung cancer 1.5%
Aortic aneurysm 1%
Aortic stenosis 1%
Herpes zoster 1%
SYMPTOMS AND SIGNS ACCORDING TO LIKELY ETIOLOGY
COSTOCHONDRAL OR CHEST WALL PAIN
Localized sharp/stabbing or persistent/dull pain ,reproduced by pressure over the painful area.
CERVICAL OR THORACIC SPINE DISEASE WITH NERVE ROOT COMPRESSION
Sharp pain,may be in radicular distribution ,exacerbated by movement of neck,back.
ESOPHAGEAL OR GASTRIC PAIN
Associated with dysphagia or gastric regurgitation,may be worsened by aspirin/alcohol ingestion/certain foods/supine position: often relieved by antacids.
BILIARY PAIN
Intolerance of fatty foods, right upper quadrant tenderness also present.
MYOCARDIAL ISCHEMIA
Precipitated by exertion or emotional arousal .ECG ( or holter monitor ) during pain shows ST segment shifts ,pain relieved quickly ( < 5 minutes ) by sublingual TNG
DIFFERENTIAL DIAGNOSIS OF ACUTE CHEST PAIN
1.
*DESCRIPTION OF PAIN
Oppressive,constrictive ,or squeezing ,may radiate to arms ,neck and back.
*BACKGROUND HISTORY
Less severe ,similar pain on exertion plus coronary risk factors.
*KEY PHYSICAL FINDINGS
Diaphoresis ,pallor S4 common .S3 less common.
*CONSIDER
Acute Myocardial Infarction.
*CONFIRMATORY TESTS
Serial ECGs ,Serial cardiac markers ( especially troponin ,CK )
2.
*DESCRIPTION OF PAIN
tearing or ripping may travel from anterior chest to mid back.
*BACKGROUND HISTORY
Hypertension or Marfan syndrome.
*KEY PHYSICAL FINDINGS
Weak,asymptomatic peripheral pulses ,possible diastoic murmur or aortic insufficiency.
*CONSIDER
Aortic Dissection
*CONFIRMATORY TESTS
CXR -Widened mediastinal silhoutte ,MRI .CT ,or transesophageal echogram ,intimal flap visualized.Aortic angiogram ,definitive diagnosis.
3.
*DESCRIPTION OF PAIN
Crushing ,sharp ,pleuritic ,relieved by sitting forward.
*BACKGROUND HISTORY
recent upper respiratory tract infection ,or other conditions which predispose to pericarditis.
*KEY PHYSICAL FINDINGS
Pericardial friction rub ( usually 3 component best heard by sitting patient forward )
*CONSIDER
Acute pericarditis
*CONFIRMATORY TESTS
ECG ,diffuse ST elevation and PR segment depression. Echogram ,pericardial effusion often visualized.
4.
*DESCRIPTION OF PAIN
Pleuritic ,sharp possibly accompanied by cough /hemoptysis
*BACKGROUND HISTORY
Recent surgery or other immobilization
*KEY PHYSICAL FINDINGS
Tachypnea ,possible pleural friction rub.
*CONSIDER
Pulmonary Embolism
*CONFIRMATORY TESTS
Arterial blood gas ,hypoxemia and respiratoy alkalosis ,Lung scan ,V/Q mismatch ,pulmonary angiogram ,arterial luminal filling defects.
5.
*DESCRIPTION OF PAIN
Very sharp, pleuritic
*BACKGROUND HISTORY
recent chest ,or history of chronic obstructive lung disease.
*KEY PHYSICAL FINDINGS
tachypnea ,breath sounds and hyperesonance over affected lung field
*CONSIDER
Acute Pneumothorax
*CONFIRMATORY TESTS
CXR ,radioluency within pleural space poss ,collapse of adjacent lung segment , If tension pneumothorax mediastinum is shifted to opposite side.
6.
*DESCRIPTION OF PAIN
Intense substernal and epigastric accompanied by vomiting and/or hemoptysis.
*BACKGROUND HISTORY
Recent recurrent vomiting /retching
*KEY PHYSICAL FINDINGS
Subcutaneous emphysema ,audible crepitus adjacent to the sternum.
*CONSIDER
Rupture of esophagus
*CONFIRMATORY TESTS
CXR pneumomediastinum .Esophageal endoscopy is diagnostic
DIFFERENTIAL DIAGNOSIS OF PATIENTS ADMITTED TO HOSPITAL WITH ACUTE CHEST PAIN RULED NOT MYOCARDIAL INFARCTION
Gastroesophageal Disease 42%
*Gastroesophageal reflux
*esophageal motility disorders
*Peptic ulcer
*Gallstones
Ischemic Heart Disease 31%
Chest Wall Syndrome 28%
Pericarditis 4%
Pleuritic/pneumonia 2%
Pulmonary embolism 2%
Lung cancer 1.5%
Aortic aneurysm 1%
Aortic stenosis 1%
Herpes zoster 1%
