Chest Pain (cont.)

Pain can be caused by almost every structure in the chest. Different organs can produce different types of pain but unfortunately the pain is not specific to each cause. Each of the following causes is explained in detail in this article:

• Broken or bruised ribs
• Pleuritis or pleurisy
• Pneumothorax
• Shingles
• Pneumonia
• Pulmonary embolus
• Angina
• Heart attack (myocardial infarction)
• Pericarditis
• The aorta and aortic dissection
• The esophagus and reflux esophagitis
• Referred abdominal pain

The key to diagnosis remains the patient history. Learning about the nature of the pain will give the health care professional direction as to what are reasonable diagnoses to consider, and what are reasonable to exclude. Understanding the quality and quantity of the pain, its associated symptoms and the risk factors for disease, can help the doctor assess the probability of each potential cause and make decisions about what potential diagnoses should be considered and which should be discarded.

Differential diagnosis is a thought process that health care professionals use to consider and then eliminate potential causes for an illness. As more information is gathered, either from history and physical examination or testing, the potential diagnosis list is narrowed until the final answer is achieved. As well, the patient's response to therapy can expand or narrow the differential diagnosis list. In patients with chest pain, many potential conditions may be present, and the health care professional will want to first consider those that are life-threatening. Using laboratory and X-ray tests may not be necessary to exclude potentially lethal diseases like heart attack, pulmonary embolus, or aortic dissection when clinical skill and judgment may be all that is needed.

The patient may be asked a variety of questions to help the health care professional understand the quality and quantity of the pain. Patients use different words to describe pain, and it is important that the health care professional get an accurate impression of the situation. The questions may also be asked in different ways.

• When did the pain start?
• What is the quality of the pain?
• How long does the pain last?
• Does the pain come and go?
• What makes the pain better?
• What makes the pain worse?
• Does the pain radiate somewhere (move to another area of the body)?
• Has there been any preceding illness?
• Has there been any trauma?
• Have there been similar episodes of pain in the past?
• Is the pain different than that of a previous condition that has been experienced, or is it similar?

• Is there shortness of breath?
• Fever or chills?
• Cough?
• Nausea or vomiting?
• Sweating?

• Smoking
• High blood pressure
• High cholesterol
• Diabetes
• Family history

• Prolonged inactivity such as bed rest, long car or airplane trips
• Recent surgery
• Fractures
• Birth control pill use (particularly if the patient smokes cigarettes)
• Cancer

• High blood pressure
• Marfan syndrome
• Ehlers-Danlos syndrome
• Polycystic kidney disease
• Cocaine use
• Pregnancy

Physical examination helps refine the differential diagnosis. While chest pain may be the initial complaint, often the whole body needs to be examined. Example components of the physical exam may include:

• Blood pressure (BP), pulse rate (PR), respiratory rate (RR), temperature, and
• Oxygen saturation (O2 sat) which measures the amount of oxygen being carried by red blood cells in the bloodstream.

• Looking for neck vein distension or bulging
• Listening over the carotid arteries for bruits (abnormal sounds) or murmurs that begin in the heart and radiate to the neck

• Palpate for rib or muscle tenderness
• Look for rashes including the rash of shingles (zoster)

• Listen for abnormal lung sounds like crackle or wheeze or decreased air entry with inspiration
• Listen for rubs (a friction sound made by two rough surfaces rubbing against each other) that may be heard in pleurisy

• Listen for abnormal heart sounds, murmurs or rubs (which may be heard with inflammation of the heart lining, called pericarditis)
• Listen for muffled or indistinct heart tones that can be associated with excess fluid in the pericardium, the sac that surrounds the heart

• Palpate for tenderness or masses
• Listen for bruits over the aorta

• Feel for pulses