Chest pain is a common presenting symptoms of disorders that can range from trivial to life threatening.
- Cardiovascular: (Angina, Myocardial infarction,Acute aortic dissection,Pericarditis)
- Gastrointestinal:(Reflux esophagitis, Peptic ulcer disease, esophageal spasm)
- Pulmonary: (Pneumonia, Pneumothorax, Pulmonary embolism)
- Musculoskeletal: (Chest wall injuries, Herpes zoster, Costochondritis, Secondary tumors of the rib)
- Emotional: (Depression)
Evaluation by history:
- The character of angina is tight and crushing, while the pain from aortic dissection has a tearing quality. Esophageal reflux may be described as a burning pain, and peptic acid-related pain tends to be deep and gnawing.
- Location: the pain from angina and esophageal reflux may be located retrosternally, and they both can radiate to the jaw or down into the left arm.
- The pain from pericarditis may be centrally located and radiate to the shoulders (trapezius ridge pain).
- Pain from aortic dissection often radiate =s into the back and occasionally into the abdomen (depending on the extent of the dissection) . pulmonary pain can be located anywhere in the thorax.
- Angina may be precipitated by effort, a defining characteristics. Other known precipitants of angina are emotion, food and cold weather. If angina occurs at rest for more than 20 minutes it should be treated as a myocardial infarction until proven otherwise.
- Esophageal reflux is often related to meals and precipitated by changes in posture, such as bending or lying.
- Pain originating from pericarditis and pulmonary origin is often pleuritic, i.e worse on inspiration, however musculoskeletal pain can also be worse on breathing due to movement of the thorax.
- Both esophageal spasm and angina may be relieved by GTN (glyceral trinitrite?) which relaxes smooth muscle.
- Antacids will relieve the pain of esophageal reflux but not angina.
- The pain associated with pericarditis may be relieved by sitting forwards.
History of trauma: A blunt or stretching injury immediately suggests the underlying etiology of chest wall tenderness and it is important to diagnose rib fractures that can result from more severe trauma.
Emotion: Occasionally chest pain is a somatic manifestation of patients with depression or anxiety but it is essential to exclude all organic causes before accepting depression or anxiety as the underlying cause. Moreover a serious etiology may co-exist.
- Temperature: Pyrexia can occur with pneumonia, myocardial infarction, pericarditis and herpes zoster infection.
- Pulse: Heart rate on its own is not discriminating as pain invariably leads to tachycardia. However palpating both upper and lower limb pulses may be useful. Occasionally peripheral pulses are absent in patients with aortic dissection.
- JVP: The JVP is elevated with congestive cardiac failure and acute right ventricular failure, an occasional complication of inferior myocardial infarction and pulmonary embolism (when more than 60% of the pulmonary vascular supply is occluded).
Palpation of the chest:
Chest wall tenderness would imply a musculoskeletal cause. The presence of unilateral tenderness confined to a single or adjacent group of dermatomes would suggest either central ( vertebral or spinal origin) or peripheral nerve pathology (herpes zoster infection).
The trachea deviates away from the side of tension pneumothorax and chest expansion is decreased on the same side of pneumonia and pneumothorax. Dullness to percussion will be noted in an area of consolidation with pneumonia and hyperresonance with pneumothorax.
Auscultation of the chest:
The unilateral absence of breath sounds is consistent with a pneumothorax, more localized loss occurs over an effusion. Localized areas of crepitation suggest lobar pneumonia while widespread crepitation suggest multilobar involvement. A friction rub may be auscultated with both pericardial and pleuritic disease.
Lower limbs: hemiparesis can occur with aortic dissection, and a hot swollen, tender calf or thigh may give a clue to an underlying deep vein thrombosis.
- ECG: Angina or a myocardial infarction will result in ecg changes. So it is important investigation for evaluation of chest pain.
- FBC: A elevated white count will be expected with pneumonia and to a lesser extent in a myocardial infarction.(2) Serum Cardiac markers. Following a myocardial infarction, cardiac troponin rises within 6 hours and remains elevated for up to 2 weeks.
- Chest X ray. It helps to rule out any pathology in the lungs and also any fracture in the ribs.
- V/Q scan: It will show a mismatch in the majority of pulmonary embolism.
- Pulmonary angiography: It is possible to visualise the site and extent of the embolism and it may also be possible to extract the emboli using the catheter.
- CT aortography: Confirm and asses the extent and site of the dissection of the aorta.
- Upper GI tract endoscopy: Esophagitis
- Esophageal manometry: Abnormal esophageal pressure
The heart score for a patient of chest pain in emergency department.
It is important to perform a prompt history, examination and initial investigations in patients who present with chest pain as a number of conditions require urgent management.If tension pneumothorax is suspected as a cause of chest pain, do not wait for a chest film. Decompress the pneumothorax immediately with a large-bore cannula inserted into 2nd intercostal space in the midclavicular line.