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Diseases » Chest pain » Causes
 

Causes of Chest pain

Contents
  1. Chest pain: Introduction
  2. List of Causes
  3. Drugs/substances (848 causes)
  4. Drug interaction (323 causes)
  5. Hidden causes
  6. Excerpts from book chapters
  7. Complication causes
  8. Causes of symptoms
  9. News
  10. Related cause information

List of causes of Chest pain

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Chest pain) that could possibly cause Chest pain includes:

More causes: see full list of causes for Chest pain

Causes of Chest pain (Diseases Database):

The follow list shows some of the possible medical causes of Chest pain that are listed by the Diseases Database:

Source: Diseases Database

Chest pain Causes: Book Excerpts

Chest pain as a complication of other conditions:

Other conditions that might have Chest pain as a complication may, potentially, be an underlying cause of Chest pain. Our database lists the following as having Chest pain as a complication of that condition:

Chest pain as a symptom:

Conditions listing Chest pain as a symptom may also be potential underlying causes of Chest pain. Our database lists the following as having Chest pain as a symptom of that condition:

Medications or substances causing Chest pain:

The following drugs, medications, substances or toxins are some of the possible causes of Chest pain as a symptom. This list is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

See full list of 848 medications causing Chest pain


Drug interactions causing Chest pain:

When combined, certain drugs, medications, substances or toxins may react causing Chest pain as a symptom.

The list below is incomplete and various other drugs or substances may cause your symptoms. Always advise your doctor of any medications or treatments you are using, including prescription, over-the-counter, supplements, herbal or alternative treatments.

  • Dymelor and alcohol interaction
  • Diabinese and alcohol interaction
  • Amaryl and alcohol interaction
  • Glucotrol and alcohol interaction
  • Glucotrol XL and alcohol interaction
  • more interactions...»

See full list of 323 drug interactions causing Chest pain

Medical news summaries relating to Chest pain:

The following medical news items are relevant to causes of Chest pain:

Related information on causes of Chest pain:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Chest pain may be found in:

Causes of Chest pain: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Chest pain.

Chest Pain: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Cardiovascular etiologies
    –Myocardial infarction
    –Angina
    –Acute coronary syndrome
    –Pulmonary embolus
    –Pericarditis
    –Arrhythmias
    –Mitral valve prolapse
    –Aortic stenosis
    –Aortic dissection
    –Cardiac tamponade
  • Pulmonary etiologies
    –Pneumonia
    –COPD
    –Asthma
    –Pneumothorax
    –Tension pneumothorax
    –Hemothorax
    –Empyema
    –Pneumomediastinum
    –Lung cancer
  • Gastrointestinal etiologies
    –Esophagitis/GERD
    –Gastritis
    –Peptic ulcer disease
    –Perforated ulcer
    –Esophageal spasm
    –Pancreatitis
    –Esophageal rupture
    –Pneumoperitoneum
  • Musculoskeletal etiologies
    –Muscle strain or spasm
    –Intercostal muscle spasm
    –Costochondritis
    –Trauma (e.g., rib fracture)
  • Zoster
  • Cancer (e.g., lymphoma)
  • Panic disorder
  • Less common etiologies include Tietze's syndrome, Pott's disease (tuberculosis of the spine), xyphodenia, cholecystitis, peritonitis, liver cancer, and hepatitis

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Flank Pain/CVA Tenderness: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Degenerative disk disease and/or disk herniation is the most frequent cause of pain
  • Muscle spasm or cramping
  • Trauma
  • Nephrolithiasis/urolithiasis (renal or ureteral calculi or stones) is the most common urinary tract etiology
  • Pyelonephritis (acute or chronic)
    –E. coli is the most common cause of upper and lower urinary infections, followed by Staphylococcus saprophyticus
    –Acute pyelonephritis is usually a complication of a lower UTI
    –Chronic pyelonephritis is usually associated with obstruction
    • Perirenal (kidney) abscess
    • Acute pancreatitis
    • Glomerulonephritis
    • Herpes zoster
    • Bacterial cystitis
    • Polycystic kidney disease
    • Renal infarction or trauma
    • Papillary necrosis
    • Duodenal ulcer
    • Cholecystitis or biliary colic
    • Pneumonia
    • Appendicitis
    • Obstructive uropathy
    • Ectopic pregnancy
    • Cervicitis
    • Renal or bladder cancer
    • Leaking or ruptured abdominal aortic aneurysm

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Chest Pain: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

  • Musculoskeletal
    –Sharp, stabbing pain that is usually very well localized, often worsened by deep breath or cough
    –Costochondritis: Tender parasternal pain at insertion of ribs into cartilage en route to sternum; increases with palpation or mild chest compression (possibly postviral)
    –Injury to chest wall
  • Pulmonary
    –Very common cause, usually associated with respiratory symptoms: Shortness of breath, cough, exercise intolerance
    –Asthma (most common), often only EIA; may have personal/family history of atopy (asthma, eczema, seasonal allergies); shortness of breath is usually primary complaint, with feeling of chest tightness/pain as a secondary symptom
    –Pleuritic chest pain: Sharp, stabbing pain with deep breaths, indicates pleural space inflammation, probably postinfectious (especially viral)
    –Pneumonia: Chest pain secondary to cough or pleural involvement
    –Pneumothorax can occur spontaneously, especially in tall, thin athletes
  • Gastrointestinal
    –GERD and PUD: Burning, substernal pain with eating, worse at night
    –Rarely pancreatitis (with back pain too), cholecystitis, hiatal hernia, hepatitis
  • Cardiac: Rare in children
    –Precordial catch syndrome: Sharp, brief (seconds) chest pain usually associated with rising from lying or sitting; unclear etiology, but of no significance
    –Pericarditis: Inflammation of the pericardium; often postviral, may represent connective tissue/autoimmune, cancer, bacterial infection (very ill appearing with fever), or post-cardiac surgery; patients often lean forward to decrease the pain
    –MI (rare): Congenital coronary anomaly, post-Kawasaki, cocaine use, hypertrophic cardiomyopathy
    –Aortic dissection: Consider if features or history of Marfan syndrome is present

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Chest expansion, asymmetrical: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Bronchial obstruction.

 Life-threatening loss of airway patency may occur gradually or suddenly. Typically, a lack of chest movement indicates complete obstruction; chest lag signals partial obstruction. If air is trapped in the chest, you may detect intercostal bulging during expiration and hyperresonance on percussion. You may also note dyspnea, accessory muscle use, decreased or absent breath sounds, and suprasternal, substernal, or intercostal retractions.

Flail chest.

With flail chest, a life-threatening injury to the ribs or sternum, the unstable portion of the chest wall collapses inward during inspiration and balloons outward during expiration (paradoxical movement). The patient may have ecchymoses, severe localized pain, or other signs of traumatic injury to the chest wall. He may also exhibit rapid, shallow respirations, tachycardia, and cyanosis.

Hemothorax.

Hemothorax is life-threatening bleeding into the pleural space that causes chest lag during inspiration. Other findings include signs of traumatic chest injury, stabbing pain at the injury site, anxiety, dullness on percussion, tachypnea, tachycardia, and hypoxemia. If hypovolemia occurs, you'll note signs of shock, such as hypotension and a rapid, weak pulse.

Kyphoscoliosis.

 Abnormal curvature of the thoracic spine in the anteroposterior direction (kyphosis) and the lateral direction (scoliosis) gradually compresses one lung and distends the other. This produces decreased chest wall movement on the compressed-lung side and expands the intercostal muscles during inspiration on the opposite side. It can also produce ineffective coughing, dyspnea, back pain, and fatigue.

Myasthenia gravis

 Progressive loss of ventilatory muscle function produces asynchrony of the chest and abdomen during inspiration (“abdominal paradox”), which can lead to the onset of acute respiratory distress. Typically, the patient's shallow respirations and increased muscle weakness cause severe dyspnea, tachypnea, and possible apnea.

Pleural effusion.

 Chest lag at end-inspiration occurs gradually in this life-threatening accumulation of fluid, blood, or pus in the pleural space. Usually, some combination of dyspnea, tachypnea, and tachycardia precedes chest lag; the patient may also have pleuritic pain that worsens with coughing or deep breathing. The area of the effusion is delineated by dullness on percussion and by egophony, bronchophony, whispered pectoriloquy, decreased or absent breath sounds, and decreased tactile fremitus. A fever appears if infection causes the effusion.

Pneumonia.

Depending on whether fluid consolidation in the lungs develops unilaterally or bilaterally, asymmetrical chest expansion occurs as inspiratory chest lag or as chest-abdomen asynchrony. The patient typically has a fever, chills, tachycardia, tachypnea, and dyspnea along with crackles, rhonchi, and chest pain that worsens during deep breathing. He may also be fatigued and anorexic and have a productive cough with rust-colored sputum.

Pneumothorax.

Entrapment of air in the pleural space can cause chest lag at end-inspiration. Pneumothorax, a life-threatening condition, also causes sudden, stabbing chest pain that may radiate to the arms, face, back, or abdomen and dyspnea unrelated to the chest pain's severity. Other findings include tachypnea, decreased tactile fremitus, tympany on percussion, decreased or absent breath sounds over the trapped air, tachycardia, restlessness, and anxiety.

With tension pneumothorax, the same signs and symptoms occur as in pneumothorax, but they're much more severe. Tension pneumothorax rapidly compresses the heart and great vessels, causing cyanosis, hypotension, tachycardia, restlessness, and anxiety. The patient may also develop subcutaneous crepitation of the upper trunk, neck, and face and mediastinal and tracheal deviation away from the affected side. You may auscultate a crunching sound over the precordium with each heartbeat; this indicates pneumomediastinum.

Pulmonary embolism.

Pulmonary embolism is an acute, life-threatening disorder that causes chest lag; sudden, stabbing chest pain; and tachycardia. The patient usually has severe dyspnea, blood-tinged sputum, a pleural friction rub, and acute anxiety.

Other causes

Treatments.

 Asymmetrical chest expansion can result from pneumonectomy and the surgical removal of several ribs. Chest lag or the absence of chest movement may also result from intubation of a mainstem bronchus, a serious complication typically due to the incorrect insertion of an endotracheal tube or movement of the tube while it's in the trachea.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Flank pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Calculi

Renal and ureteral calculi produce intense unilateral, colicky flank pain. Typically, initial CVA pain radiates to the flank, suprapubic region, and perhaps the genitalia; abdominal and lower back pain are also possible. Nausea and vomiting commonly accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of a UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, a low-grade fever, and tenesmus)

Cortical necrosis (acute)

Unilateral flank pain is usually severe. Accompanying findings include gross hematuria, anuria, leukocytosis, and a fever

Obstructive uropathy

With acute obstruction, flank pain may be excruciating; with gradual obstruction, it’s typically a dull ache. With both, the pain may also localize in the upper abdomen and radiate to the groin. Nausea and vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and hypoactive bowel sounds may also occur. Additional findings — a palpable abdominal mass, CVA tenderness, and bladder distention — vary with the site and cause of the obstruction

Papillary necrosis (acute)

Intense bilateral flank pain occurs along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms include oliguria or anuria, hematuria, and pyuria, with associated high fever, chills, vomiting, and hypoactive bowel sounds

Perirenal abscess

Intense unilateral flank pain and CVA tenderness accompany dysuria, a persistent high fever, chills and, in some patients, a palpable abdominal mass

Polycystic kidney disease

Dull, aching, bilateral flank pain is commonly the earliest symptom of polycystic kidney disease. The pain can become severe and colicky if cysts rupture and clots migrate or cause obstruction. Nonspecific early findings include polyuria, increased blood pressure, and signs of a UTI. Later findings include hematuria and perineal, low back, and suprapubic pain

Pyelonephritis (acute)

Intense, constant, and unilateral or bilateral flank pain develops over a few hours or days along with typical urinary features: dysuria, nocturia, hematuria, urgency, frequency, and tenesmus. Other common findings include a persistent high fever, chills, anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness

Renal cancer

Unilateral flank pain, gross hematuria, and a palpable flank mass form the classic clinical triad. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include a fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease

Renal infarction

Unilateral, constant, severe flank pain and tenderness typically accompany persistent, severe upper abdominal pain. The patient may also develop CVA tenderness, anorexia, nausea and vomiting, a fever, hypoactive bowel sounds, hematuria, and oliguria or anuria

Renal trauma

Variable bilateral or unilateral flank pain is a common symptom. A visible or palpable flank mass may also exist, along with CVA or abdominal pain — which may be severe and radiate to the groin. Other findings include hematuria, oliguria, abdominal distention, Turner’s sign, hypoactive bowel sounds, and nausea or vomiting. Severe injury may produce signs of shock, such as tachycardia and cool, clammy skin

Renal vein thrombosis

Severe unilateral flank and lower back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include a  fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms (nausea, vomiting, and uremic fetor) typify bilateral obstruction

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Chest pain: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Angina pectoris.

 With angina pectoris, the patient may experience a feeling of tightness or pressure in the chest that he describes as pain or a sensation of indigestion or expansion. The pain usually occurs in the retrosternal region over a palm-sized or larger area. It may radiate to the neck, jaw, and arms — classically, to the inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, and then slowly subside. Provoked by exertion, emotional stress, or a heavy meal, the pain typically lasts 2 to 10 minutes (usually no longer than 20 minutes). Associated findings include dyspnea, nausea, vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations. You may hear an atrial gallop (a fourth heart sound) or murmur during an anginal episode.

With Prinzmetal's angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest — or it may awaken him. It may be accompanied by shortness of breath, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop.

Anthrax (inhalation).

Anthrax is an acute infectious disease that's caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in a cutaneous, inhalation, or GI form.

Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Anxiety.

 Acute anxiety — or, more commonly, panic attacks — can produce intermittent, sharp, stabbing pain, commonly located behind the left breast. This pain isn't related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, a headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia — fear of leaving home or being in open places with other people.

Aortic aneurysm (dissecting).

 The chest pain associated with a dissecting aortic aneurysm usually begins suddenly and is most severe at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest and neck that radiates to his upper back, abdomen, and lower back. He may also have abdominal tenderness, a palpable abdominal mass, tachycardia, murmurs, syncope, blindness, loss of consciousness, weakness or transient paralysis of the arms or legs, a systolic bruit, systemic hypotension, asymmetrical brachial pulses, a lower blood pressure in the legs than in the arms, and weak or absent femoral or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid arteries.

Asthma.

 In a life-threatening asthma attack, diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related respiratory findings include rhonchi, crackles, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, and tachypnea. The patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.

Bronchitis.

In its acute form, bronchitis produces a burning chest pain or a sensation of substernal tightness. It also produces a cough, initially dry but later productive, that worsens the chest pain. Other findings include a low-grade fever, chills, a sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101° to 102° F (38.3° to 38.9° C) and possible bronchospasm with worsening wheezing and increased coughing.

Cholecystitis.

 Cholecystitis typically produces abrupt epigastric or right upper quadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may radiate to the back or right shoulder. Commonly associated findings include nausea, vomiting, a fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an abdominal mass, rigidity, distention, or tenderness. Murphy's sign — inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath — may also occur.

Interstitial lung disease.

As interstitial lung disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, a nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.

Lung abscess.

Pleuritic chest pain develops insidiously in lung abscess along with a pleural friction rub and a cough that raises copious amounts of purulent, foul-smelling, blood-tinged sputum. The affected side is dull to percussion, and decreased breath sounds and crackles may be heard. The patient also displays diaphoresis, anorexia, weight loss, a fever, chills, fatigue, weakness, dyspnea, and clubbing.

Lung cancer.

 The chest pain associated with lung cancer is commonly described as an intermittent aching felt deep within the chest. If the tumor metastasizes to the ribs or vertebrae, the pain becomes localized, continuous, and gnawing. Associated findings include cough (sometimes bloody), wheezing, dyspnea, fatigue, anorexia, weight loss, and a fever.

Mitral valve prolapse.

 Most patients with mitral valve prolapse are asymptomatic, but some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can last for seconds or for hours and occasionally mimics the pain of ischemic heart disease. The characteristic sign of mitral prolapse is a midsystolic click followed by a systolic murmur at the apex. Patients may experience cardiac awareness, a migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations.

Myocardial infarction (MI).

 The chest pain during an MI lasts from 15 minutes to hours. Typically a crushing substernal pain unrelieved by rest or nitroglycerin, it may radiate to the patient's left arm, jaw, neck, or shoulder blades. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, an atrial gallop, murmurs, and crackles.

GENDER CUE: Chest pain in perimenopausal women may be difficult to diagnose because it may be atypical. Fatigue, nausea, dyspnea, and shoulder or neck pain are symptoms more likely to signal an MI in women than in men.

Pancreatitis.

In the acute form, pancreatitis usually causes intense pain in the epigastric area that radiates to the back and worsens when the patient is in a supine position. Nausea, vomiting, a fever, abdominal tenderness and rigidity, diminished bowel sounds, and crackles at the lung bases may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes massive hemorrhage, resulting in shock and coma.

Peptic ulcer.

 With a peptic ulcer, sharp and burning pain usually arises in the epigastric region. This pain characteristically arises hours after food intake, commonly during the night. It lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood), melena, and epigastric tenderness.

Pericarditis.

Pericarditis produces precordial or retrosternal pain aggravated by deep breathing, coughing, position changes, and occasionally by swallowing. The pain is commonly sharp or cutting and radiates to the shoulder and neck. Associated signs and symptoms include a pericardial friction rub, a fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered.

Plague (Yersinia pestis).

Plague is one of the most virulent bacterial infections and, if untreated, one of the most potentially lethal diseases known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to a human when bitten by an infected flea. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the flea bite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The pneumonic form may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, a fever, a headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pleurisy.

 The chest pain of pleurisy arises abruptly and reaches maximum intensity within a few hours. The pain is sharp, even knifelike, usually unilateral, and located in the lower and lateral aspects of the chest. Deep breathing, coughing, or thoracic movement characteristically aggravates it. Auscultation over the painful area may reveal decreased breath sounds, inspiratory crackles, and a pleural friction rub. Dyspnea; rapid, shallow breathing; cyanosis; a fever; and fatigue may also occur.

Pneumonia.

Pneumonia produces pleuritic chest pain that increases with deep inspiration and is accompanied by shaking chills and fever. The patient has a dry cough that later becomes productive. Other signs and symptoms include crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, a headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis.

Pneumothorax.

Spontaneous pneumothorax, a life-threatening disorder, causes sudden sharp chest pain that's severe, typically unilateral, and rarely localized; it increases with chest movement. When the pain is centrally located and radiates to the neck, it may mimic that of an MI. After the pain's onset, dyspnea and cyanosis progressively worsen. Breath sounds are decreased or absent on the affected side with hyperresonance or tympany, subcutaneous
crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory muscle use, a nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.

Pulmonary embolism.

A pulmonary embolism produces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain aggravated by deep breathing and thoracic movement. Other findings include tachycardia, tachypnea, a cough (nonproductive or producing blood-tinged sputum), a low-grade fever, restlessness, diaphoresis, crackles, a pleural friction rub, diffuse wheezing, dullness to percussion, signs of circulatory collapse (a weak, rapid pulse; hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness, coma, seizures), signs of hypoxia (restlessness) and, particularly in the elderly, hemiplegia and other focal neurologic deficits. Less common signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and jugular vein distention.

Q fever.

Q fever is a rickettsial disease caused by Coxiella burnetii. The primary source of human infection results from exposure to infected animals. Cattle, sheep, and goats are most likely to carry the organism. Human infection results from exposure to contaminated milk, urine, feces, or other fluids from infected animals. Infection may also result from inhaling contaminated barnyard dust. C. burnetii is highly infectious and is considered a possible airborne agent for biological warfare. Signs and symptoms include a fever, chills, a severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Sickle cell crisis.

Chest pain associated with sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain worsens, it becomes generalized or localized to the abdomen or chest, causing severe pleuritic pain. The presence of chest pain and difficulty breathing requires prompt intervention. The patient may also have abdominal distention and rigidity, dyspnea, a fever, and jaundice.

Thoracic outlet syndrome.

Commonly causing paresthesia along the ulnar distribution of the arm, thoracic outlet syndrome can be confused with angina, especially when it affects the left arm. The patient usually experiences angina-like pain after lifting his arms above his head, working with his hands above his shoulders, or lifting a weight. The pain disappears as soon as he lowers his arms. Other signs and symptoms include pale skin and a difference in blood pressure between both arms.

Tuberculosis (TB).

In a patient with TB, pleuritic chest pain and fine crackles occur after coughing. Associated signs and symptoms include night sweats, anorexia, weight loss, a fever, malaise, dyspnea, easy fatigability, a mild to severe productive cough, occasional hemoptysis, dullness to percussion, increased tactile fremitus, and amphoric breath sounds.

Tularemia.

Also known as rabbit fever, tularemia is an infectious disease that's caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. It's typically a rural disease found in wild animals, water, and moist soil. It's transmitted to humans through a bite by an infected insect or tick, handling infected animal carcasses, drinking contaminated water, or inhaling the bacteria. It's considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Chinese restaurant syndrome (CRS).

CRS is a benign condition — a reaction to excessive ingestion of monosodium glutamate, a common additive in Chinese foods — that mimics the signs of an acute MI. The patient may complain of retrosternal burning, ache, or pressure; a burning sensation over his arms, legs, and face; a sensation of facial pressure; a headache; shortness of breath; and tachycardia.

Drugs.

 The abrupt withdrawal of a beta-adrenergic blocker can cause rebound angina if the patient has coronary heart disease — especially if he has received high doses for a prolonged period.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Chest expansion, asymmetrical: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Bronchial obstruction

Life-threatening loss of airway patency may occur gradually or suddenly in bronchial obstruction. Typically, lack of chest movement indicates complete obstruction; chest lag signals partial obstruction. If air is trapped in the chest, you may detect intercostal bulging during expiration and hyperresonance on percussion. You may also note dyspnea, accessory muscle use, decreased or absent breath sounds, and suprasternal, substernal, or intercostal retractions.

Flail chest

In this life-threatening injury to the ribs or sternum, the unstable portion of the chest wall collapses inward during inspiration and balloons outward during expiration (paradoxical movement). The patient may have ecchymoses, severe localized pain, or other signs of traumatic injury to the chest wall. He may also exhibit rapid, shallow respirations, tachycardia, and cyanosis.

Hemothorax

Hemothorax is life-threatening bleeding into the pleural space that causes chest lag during inspiration. Other findings include signs of traumatic chest injury, stabbing pain at the injury site, anxiety, dullness on percussion, tachypnea, tachycardia, and hypoxemia. If hypovolemia occurs, you’ll note signs of shock, such as hypotension and rapid, weak pulse.

Kyphoscoliosis

Abnormal curvature of the thoracic spine in the anteroposterior direction (kyphosis) and the lateral direction (scoliosis) gradually compresses one lung and distends the other. This produces decreased chest wall movement on the compressed-lung side and expands the intercostal muscles during inspiration on the opposite side. It can also produce ineffective coughing, dyspnea, back pain, and fatigue.

Myasthenia gravis

Progressive loss of ventilatory muscle function produces asynchrony of the chest and abdomen during inspiration (“abdominal paradox”), which can lead to acute respiratory distress. Typically, the patient’s shallow respirations and increased muscle weakness cause severe dyspnea, tachypnea and, possibly, apnea.

Phrenic nerve dysfunction

In this disorder, the paralyzed hemidiaphragm fails to contract downward, causing asynchrony of the thorax and upper abdomen on the affected side during inspiration (“abdominal paradox”). Its onset may be sudden, as in trauma, or gradual, as in infection or spinal cord disease. If the patient has underlying pulmonary dysfunction that contributes to hyperventilation, his inability to breathe deeply or to cough effectively may cause atelectasis of the affected lung.

Pleural effusion

Chest lag at end-inspiration occurs gradually in this life-threatening accumulation of fluid, blood, or pus in the pleural space. Usually, some combination of dyspnea, tachypnea, and tachycardia precedes chest lag; the patient may also have pleuritic pain that worsens with coughing or deep breathing. The area of the effusion is delineated by dullness on percussion and by egophony, bronchophony, whispered pectoriloquy, decreased or absent breath sounds, and decreased tactile fremitus. The patient may have a fever if infection caused the effusion.

Pneumonia

Depending on whether fluid consolidation in the lungs develops unilaterally or bilaterally, asymmetrical chest expansion occurs as inspiratory chest lag or as chest-abdomen asynchrony. The patient typically has fever, chills, tachycardia, tachypnea, and dyspnea along with crackles, rhonchi, and chest pain that worsens during deep breathing. He may also be fatigued and anorexic and have a productive cough with rust-colored sputum.

Pneumothorax

Entrapment of air in the pleural space can cause chest lag at end-inspiration. This life-threatening condition also causes sudden, stabbing chest pain that may radiate to the arms, face, back, or abdomen and dyspnea unrelated to the chest pain’s severity. Other findings include tachypnea, decreased tactile fremitus, tympany on percussion, decreased or absent breath sounds over the trapped air, tachycardia, restlessness, and anxiety.

Tension pneumothorax produces the same signs and symptoms as pneumothorax, but they’re much more severe. A tension pneumothorax rapidly compresses the heart and great vessels, causing cyanosis, hypotension, tachycardia, restlessness, and anxiety. The patient may also develop subcutaneous crepitation of the upper trunk, neck, and face and mediastinal and tracheal deviation away from the affected side. Auscultation of a crunching sound over the precordium with each heartbeat indicates pneumomediastinum.

Poliomyelitis

In this rare disorder, paralysis of the chest wall muscles and diaphragm produces chest-abdomen asynchrony (“abdominal paradox”), fever, muscle pain, and weakness. Other findings include decreased reflex response in the affected muscles and impaired swallowing and speaking.

Pulmonary embolism

This acute, life-threatening disorder causes chest lag; sudden, stabbing chest pain; and tachycardia. The patient usually has severe dyspnea, blood-tinged sputum, pleural friction rub, and acute anxiety.

Other causes

Treatments

Asymmetrical chest expansion can result from pneumonectomy and surgical removal of several ribs. Chest lag or the absence of chest movement may also result from intubation of a mainstem bronchus, a serious complication typically due to incorrect insertion of an endotracheal tube or movement of the tube while it’s in the trachea.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Flank pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Bladder cancer

Dull, constant flank pain may be unilateral or bilateral and may radiate to the leg, back, and perineum. Commonly, the first sign of bladder cancer is gross, painless, intermittent hematuria, often with clots. Related effects may include urinary frequency and urgency, nocturia, dysuria, or pyuria; bladder distention; pain in the bladder, rectum, pelvis, back, or legs; diarrhea; vomiting; and sleep disturbances.

Calculi

Renal and ureteral calculi produce intense unilateral, colicky flank pain. Typically, initial CVA pain radiates to the flank, suprapubic region, and perhaps the genitalia; abdominal and low back pain are also possible. Nausea and vomiting commonly accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, low-grade fever, and tenesmus).

Cortical necrosis (acute)

Unilateral flank pain is usually severe in this disorder. Accompanying findings include gross hematuria, anuria, leukocytosis, and fever.

Cystitis (bacterial)

Unilateral or bilateral flank pain occurs secondarily to an ascending UTI in bacterial cystitis. The patient may also report perineal, low back, and suprapubic pain. Other effects include dysuria, nocturia, hematuria, urinary frequency and urgency, tenesmus, fatigue, and low-grade fever.

Glomerulonephritis (acute)

Flank pain in patients with this disorder is bilateral, constant, and of moderate intensity. The most common findings are moderate facial and generalized edema, hematuria, oliguria or anuria, and fatigue. Other effects include slightly increased blood pressure, low-grade fever, malaise, headache, nausea, and vomiting. Accompanying signs of pulmonary congestion include dyspnea, tachypnea, and crackles.

Obstructive uropathy

In an acute obstruction, flank pain may be excruciating; in a gradual obstruction, it’s typically a dull ache. In both types, the pain may also localize in the upper abdomen and radiate to the groin. Nausea and vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and hypoactive bowel sounds may also occur. Additional findings—a palpable abdominal mass, CVA tenderness, and bladder distention—vary with the site and cause of the obstruction.

Pancreatitis (acute)

Bilateral flank pain may develop as severe epigastric or left-upper-quadrant pain radiates to the back. A severe attack causes extreme pain, nausea and persistent vomiting, abdominal tenderness and rigidity, hypoactive bowel sounds and, possibly, restlessness, low-grade fever, tachycardia, hypotension, and positive Turner’s and Cullen’s signs.

Papillary necrosis (acute)

In this disorder, intense bilateral flank pain occurs along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms—oliguria or anuria, hematuria, and pyuria—are associated with high fever, chills, vomiting, and hypoactive bowel sounds.

Perirenal abscess

Intense unilateral flank pain and CVA tenderness accompany dysuria, persistent high fever, chills and, in some patients, a palpable abdominal mass.

Polycystic kidney disease

Dull, aching, bilateral flank pain is commonly the earliest symptom of this renal disorder. The pain can become severe and colicky if cysts rupture and clots migrate or cause an obstruction. Nonspecific early findings include polyuria, increased blood pressure, and signs and symptoms of UTI. Later findings include hematuria and perineal, low back, and suprapubic pain.

Pyelonephritis (acute)

Intense, constant, unilateral or bilateral flank pain develops over a few hours or days along with typical urinary features: dysuria, nocturia, hematuria, urgency, frequency, and tenesmus. Other common findings include persistent high fever, chills, anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness.

Renal cancer

Unilateral flank pain, gross hematuria, and a palpable flank mass form the classic clinical triad in renal cancer. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease.

Renal infarction

Unilateral, constant, severe flank pain and tenderness typically accompany persistent, severe upper abdominal pain in this disorder. The patient may also develop CVA tenderness, anorexia, nausea and vomiting, fever, hypoactive bowel sounds, hematuria, and oliguria or anuria.

Renal trauma

Variable bilateral or unilateral flank pain, a visible or palpable flank mass, and CVA or abdominal pain (which may be severe and radiate to the groin) are common findings in renal trauma. Other findings include hematuria, oliguria, abdominal distention, Turner’s sign, hypoactive bowel sounds, and nausea and vomiting. Severe injury may produce signs of shock, such as tachycardia and cool, clammy skin.

Renal vein thrombosis

Severe unilateral flank and low back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms (nausea, vomiting, and uremic fetor) typify bilateral obstruction.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Chest pain: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Angina pectoris

A patient with angina pectoris may experience a feeling of tightness or pressure in the chest that he describes as pain or a sensation of indigestion or expansion. The pain usually occurs in the retrosternal region over a palm-sized or larger area. It may radiate to the neck, jaw, and arms—classically, to the inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, then slowly subside. Provoked by exertion, emotional stress, or a heavy meal, the pain typically lasts 2 to 10 minutes (usually no longer than 20 minutes). Associated findings include dyspnea, nausea, vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations. You may hear an atrial gallop (a fourth heart sound [S 4]) or a murmur during an anginal episode.

In Prinzmetal’s angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest—or it may awaken him. It may be accompanied by dyspnea, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop.

Anthrax (inhalation)

This acute infectious disease is caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological agents. Most natural cases occur in agricultural regions worldwide. Anthrax may occur in cutaneous, inhalation, or GI forms.

Inhalation anthrax is caused by inhalation of aerosolized spores. Initial flulike signs and symptoms include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly and causes rapid deterioration marked by fever, dyspnea, stridor, and hypotension; death generally results within 24 hours. Radiologic findings include mediastinitis and symmetrical mediastinal widening.

Anxiety

Acute anxiety—commonly known as panic attacks—can produce intermittent, sharp, stabbing pain, typically behind the left breast. This pain isn’t related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia—fear of leaving home or being in open places with other people.

Aortic aneurysm (dissecting)

The chest pain associated with this life-threatening disorder usually begins suddenly and is most severe at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest and neck that radiates to his upper back, abdomen, and lower back. He may also have abdominal tenderness, a palpable abdominal mass, tachycardia, murmurs, syncope, blindness, loss of consciousness, weakness or transient paralysis of the arms or legs, a systolic bruit, systemic hypotension, asymmetrical brachial pulses, lower blood pressure in the legs than in the arms, and weak or absent femoral or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid arteries.

Asthma

In a life-threatening asthma attack, diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related respiratory findings include rhonchi, crackles, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, and tachypnea. The patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.

Blast lung injury

Caused by a percussive shock wave after an explosion, blast lung injury can cause severe chest pain and possibly tearing, contusion, edema, and hemorrhage of the lungs of affected people. Worldwide terrorist activity has recently increased the incidence of this condition, which may also cause dyspnea, hemoptysis, wheezing, and cyanosis. Chest X-rays, arterial blood gas measurements, and computed tomography scans are common diagnostic tools. Although no definitive guidelines exist for caring for those with blast lung injury, treatment is based on the nature of the explosion, the environment in which it occurred, and any chemical or biological agents involved.

Blastomycosis

Besides pleuritic chest pain, this disorder initially produces signs and symptoms that mimic those of a viral upper respiratory tract infection: a dry, hacking, or productive cough (and sometimes hemoptysis), fever, chills, anorexia, weight loss, fatigue, night sweats, and malaise.

Bronchitis

In its acute form, this disorder produces burning chest pain or a sensation of substernal tightness. It also produces a cough, initially dry but later productive, that worsens the chest pain. Other findings include a low-grade fever, chills, sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101° to 102° F (38.3° to 38.9° C) and possibly bronchospasm with increased coughing and wheezing.

Cardiomyopathy

In hypertrophic cardiomyopathy, angina-like chest pain may occur with dyspnea, a cough, dizziness, syncope, gallops, murmurs, and palpitations.

Cholecystitis

This disorder typically produces abrupt epigastric or right-upper-quadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may radiate to the back or the right shoulder. Associated findings commonly include nausea, vomiting, fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an abdominal mass, rigidity, distention, or tenderness. Murphy’s sign—inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath—may also occur.

Coccidioidomycosis

In this disorder, pleuritic chest pain occurs with a dry or slightly productive cough. Other effects include fever, rhonchi, wheezing, occasional chills, sore throat, backache, headache, malaise, marked weakness, anorexia, and a macular rash.

Costochondritis

Pain and tenderness occur at the costochondral junctions, especially at the second costicartilage. The pain usually can be elicited by palpating the inflamed joint.

Distention of colon’s splenic flexure

Central chest pain may radiate to the left arm in patients with this disorder. The pain may be relieved by defecation or the passage of flatus.

Esophageal spasm

In this disorder, substernal chest pain may last up to an hour and may radiate to the neck, jaw, arms, or back. It commonly mimics the squeezing or dull sensation associated with angina. Other signs and symptoms include dysphagia for solid foods, bradycardia, and nodal rhythm.

Herpes zoster (shingles)

The pain of pre-eruptive herpes zoster may mimic that of myocardial infarction (MI). Initially, the pain is characteristically sharp, shooting, and unilateral. About 4 to 5 days after its onset, small, red, nodular lesions erupt on the painful areas—usually the thorax, arms, and legs—and the chest pain becomes burning. Associated findings include fever, malaise, pruritus, and paresthesia or hyperesthesia of the affected areas.

Hiatal hernia

Typically, this disorder produces an angina-like sternal burning (heartburn), ache, or pressure that may radiate to the left shoulder and arm. The discomfort commonly occurs after a meal when the patient bends over or lies down. Other findings include a bitter taste and pain while eating or drinking, especially spicy foods and hot drinks.

Interstitial lung disease

As this disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, a nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.

Legionnaires’ disease

This disorder produces pleuritic chest pain in addition to malaise, headache, and possibly diarrhea, anorexia, diffuse myalgia, and general weakness. Within 12 to 24 hours, the patient suddenly develops a high fever and chills, and an initially nonproductive cough progresses to a productive cough with mucoid and then mucopurulent sputum and possibly hemoptysis. Patients may also experience flushed skin, mild diaphoresis, prostration, nausea and vomiting, mild temporary amnesia, confusion, dyspnea, crackles, tachypnea, and tachycardia.

Lung abscess

Pleuritic chest pain develops insidiously in a lung abscess along with a pleural friction rub and a cough that produces copious amounts of purulent, foul-smelling, blood-tinged sputum. The affected side is dull on percussion, and decreased breath sounds and crackles may be heard. The patient also displays diaphoresis, anorexia, weight loss, fever, chills, fatigue, weakness, dyspnea, and clubbing.

Lung cancer

The chest pain associated with lung cancer is commonly described as an intermittent aching felt deep within the chest. If the tumor metastasizes to the ribs or vertebrae, the pain becomes localized, continuous, and gnawing. Associated findings include a cough (sometimes blood-tinged), wheezing, dyspnea, fatigue, anorexia, weight loss, and fever.

Mediastinitis

This disorder produces severe retrosternal chest pain that radiates to the epigastrium, back, or shoulder and may worsen with breathing, coughing, or sneezing. Accompanying signs and symptoms include chills, fever, and dysphagia.

Mitral valve prolapse

Most patients with mitral valve prolapse are asymptomatic, but some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can last for seconds or hours and may mimic the pain of ischemic heart disease. The characteristic sign of mitral prolapse is a midsystolic click followed by a systolic murmur at the apex. The patient may experience cardiac awareness, migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations.

Muscle strain

Strained chest, arm, or shoulder muscles may cause a superficial and continuous ache or “pulling” sensation in the chest. Lifting, pulling, or pushing heavy objects may aggravate this discomfort. With acute muscle strain, the patient may experience fatigue, weakness, and rapid swelling of the affected area.

Myocardial infarction

The crushing substernal chest pain typically associated with an MI lasts from 15 minutes to hours. Typically unrelieved by rest or nitroglycerin, the pain may radiate to the patient’s left arm, jaw, neck, or shoulder blades. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, an atrial gallop, murmurs, and crackles.

Gender Cue: An MI may be difficult to diagnose in perimenopausal women because it may produce atypical symptoms, such as fatigue, nausea, dyspnea, and shoulder or neck pain, rather than chest pain.

Nocardiosis

This disorder causes pleuritic chest pain with a cough that produces thick, tenacious, purulent or mucopurulent, and possibly blood-tinged sputum. Nocardiosis may also cause fever, night sweats, anorexia, malaise, weight loss, and diminished or absent breath sounds.

Pancreatitis

Acute pancreatitis usually causes intense epigastric pain that radiates to the back and worsens when the patient is in a supine position. Nausea, vomiting, fever, abdominal tenderness and rigidity, diminished bowel sounds, and crackles at the lung bases may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes massive hemorrhage, resulting in shock and coma.

Peptic ulcer

In this disorder, sharp and burning pain usually arises in the epigastric region. This pain characteristically occurs hours after food intake, commonly during the night. It lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood), melena, and epigastric tenderness.

Pericarditis

This disorder produces precordial or retrosternal pain that’s aggravated by deep breathing, coughing, position changes, and occasionally by swallowing. The pain is commonly sharp or cutting and radiates to the shoulder and neck. Associated signs and symptoms include pericardial friction rub, fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered.

Plague

Caused by Yersinia pestis, plague is one of the most virulent and, if untreated, most lethal bacterial infections known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to man from the bite of infected fleas. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the fleabite. Septicemic plague may develop as a complication of untreated bubonic or pneumonic plague and occurs when the plague bacteria enter the bloodstream and multiply. The pneumonic form can be contracted by inhaling respiratory droplets from an infected person or inhaling the organism that has been dispersed in the air through biological warfare. The onset is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pleurisy

The sharp, even knifelike chest pain of pleurisy arises abruptly and reaches maximum intensity within a few hours. The pain is usually unilateral and located in the lower and lateral aspects of the chest. Deep breathing, coughing, or thoracic movement characteristically aggravates it. Auscultation over the painful area may reveal decreased breath sounds, inspiratory crackles, and a pleural friction rub. Dyspnea, rapid and shallow breathing, cyanosis, fever, and fatigue may also occur.

Pneumonia

This disorder produces pleuritic chest pain that increases with deep inspiration and is accompanied by shaking chills and fever. The patient has a dry cough that later becomes productive. Other signs and symptoms include crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis.

Pneumothorax

Spontaneous pneumothorax, a life-threatening disorder, causes sudden severe, sharp chest pain that increases with chest movement; it’s typically unilateral and rarely localized. When the pain is centrally located and radiates to the neck, it may mimic that of an MI. After the pain’s onset, dyspnea and cyanosis progressively worsen. Breath sounds are decreased or absent on the affected side with hyperresonance or tympany, subcutaneous crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory muscle use, a nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.

Psittacosis

This disorder may produce pleuritic chest pain on rare occasions. It typically begins abruptly with chills, fever, headache, myalgia, epistaxis, and prostration.

Pulmonary actinomycosis

This disorder causes pleuritic chest pain with a cough that’s initially dry but later produces purulent sputum. The patient may also display hemoptysis, fever, weight loss, fatigue, weakness, dyspnea, and night sweats. Multiple sinuses may extend through the chest wall and drain externally.

Pulmonary embolism

This disorder produces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain aggravated by deep breathing and thoracic movement. Other findings include tachycardia, tachypnea, cough (nonproductive or producing blood-tinged sputum), low-grade fever, restlessness, diaphoresis, crackles, pleural friction rub, diffuse wheezing, dullness on percussion, signs of circulatory collapse (weak, rapid pulse; hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness, coma, seizures), signs of hypoxia (restlessness) and, particularly in the elderly, hemiplegia and other focal neurologic deficits. Less-common signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and distended neck veins.

Pulmonary hypertension (primary)

Angina-like pain develops late in patients with this disorder, usually on exertion. The precordial pain may radiate to the neck but doesn’t characteristically radiate to the arms. Typical accompanying signs and symptoms include exertional dyspnea, fatigue, syncope, weakness, cough, and hemoptysis.

Q fever

Q fever is a rickettsial disease caused by Coxiella burnetii, an organism found in cattle, sheep, and goats. Human infection usually results from exposure to contaminated milk, urine, feces, or other fluids from infected animals, but it may also result from inhalation of contaminated barnyard dust. C. burnetii is highly infectious and is considered a possible airborne agent for biological warfare. Signs and symptoms include fever, chills, severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Rib fracture

The chest pain due to fractured ribs is usually sharp, severe, and aggravated by inspiration, coughing, or pressure on the affected area. Besides shallow, splinted respirations, dyspnea, and cough, the patient experiences tenderness and slight edema at the fracture site.

Sickle cell crisis

Chest pain associated with sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain worsens, it becomes generalized or localized to the abdomen or chest, causing severe pleuritic pain. The presence of chest pain and difficulty breathing requires prompt intervention. The patient may also have abdominal distention and rigidity, dyspnea, fever, and jaundice.

Thoracic outlet syndrome

Often causing paresthesia along the ulnar distribution of the arm, this syndrome can be confused with angina, especially when it affects the left arm. The patient usually experiences angina-like pain after lifting his arms above his head, working with his hands above his shoulders, or lifting a weight. The pain disappears as soon as he lowers his arms. Other signs and symptoms include pale skin and a difference in blood pressure between both arms.

Tuberculosis

Pleuritic chest pain and fine crackles occur after coughing in a patient with tuberculosis. Associated signs and symptoms include night sweats, anorexia, weight loss, fever, malaise, dyspnea, easy fatigability, mild to severe productive cough, occasional hemoptysis, dullness on percussion, increased tactile fremitus, and amphoric breath sounds.

Tularemia

Also known as “rabbit fever,” this infectious disease is caused by the gram-negative, non–spore-forming bacterium Francisella tularensis. This organism is found in wild animals, water, and moist soil, typically in rural areas. It’s transmitted to humans through the bite of an infected insect or tick, the handling of infected animal carcasses, the drinking of contaminated water, or the inhalation of the bacterium. It’s considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of fever, chills, headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Chinese restaurant syndrome

This benign condition—a reaction to excessive ingestion of monosodium glutamate, a common additive in Chinese foods—mimics the signs of an acute MI. The patient may complain of retrosternal burning, ache, or pressure; a burning sensation over his arms, legs, and face; a sensation of facial pressure; headache; shortness of breath; and tachycardia.

Drugs

Abrupt withdrawal of a beta-adrenergic blocker can cause rebound angina if the patient has coronary artery disease, especially if he has received high doses for a prolonged period.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Flank Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Ureteral calculus

❑ Acute pyelonephritis

❑ Latissimus strain

❑ Perinephric abscess

❑ Renal infarction

❑ Renal trauma

❑ Renal cancer

❑ Mononeuritis

❑ Papillary necrosis

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Source: Field Guide to Bedside Diagnosis, 2007

Acute Nonpleuritic Chest Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Chest wall pain

❑ Angina

❑ Unstable angina

❑ Myocardial infarction

❑ Gastroesophageal reflux

❑ Herpes zoster

❑ Thoracic root compression

❑ Panic disorder

❑ Aortic stenosis

❑ Aortic dissection

❑ Mediastinal mass

❑ Biliary disease

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Source: Field Guide to Bedside Diagnosis, 2007

Pleuritic Chest Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Costochondritis

❑ Pneumonia

❑ Rib fracture

❑ Pulmonary embolism

❑ Pleurisy

❑ Pneumothorax

❑ Pericarditis

❑ Lung cancer

❑ Pneumomediastinum

❑ Splenic infarction

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Source: Field Guide to Bedside Diagnosis, 2007

Myocardial infarction: Causes
(Handbook of Diseases)

Predisposing factors include:

❑ positive family history

❑ hypertension

❑ smoking

❑ elevated levels of serum triglycerides, total cholesterol, and low-density lipoproteins

❑ diabetes mellitus

❑ obesity or excessive intake of saturated fats, carbohydrates, or salt

❑ sedentary lifestyle

❑ aging

❑ stress or a type A personality (aggressive, ambitious, competitive, addicted to work, chronically impatient)

❑ drug use, especially cocaine.

Men and postmenopausal women are more susceptible to an MI than premenopausal women, although incidence is rising among females, especially those who smoke and take a hormonal contraceptive. (See MI in women.)

The site of the MI depends on the vessels involved. Occlusion of the circumflex branch of the left coronary artery causes a lateral wall infarction; occlusion of the anterior descending branch of the left coronary artery, an anterior wall infarction.

True posterior or inferior wall infarctions generally result from occlusion of the right coronary artery or one of its branches. Right ventricular infarctions can also result from right coronary artery occlusion, can accompany inferior infarctions, and may cause right-sided heart failure. With a transmural MI, tissue damage extends through all myocardial layers; with a subendocardial MI, only in the innermost and possibly the middle layers.

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Source: Handbook of Diseases, 2003

Chest expansion, asymmetrical: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Bronchial obstruction.

With bronchial obstruction, life-threatening loss of airway patency may occur gradually or suddenly. Typically, lack of chest movement indicates complete obstruction; chest lag signals partial obstruction. If air is trapped in the chest, you may detect intercostal bulging during expiration and hyperresonance on percussion. You may also note dyspnea, accessory muscle use, decreased or absent breath sounds, and suprasternal, substernal, or intercostal retractions. With flail chest — a life-threatening injury to the ribs or ster-
num — the unstable portion of the chest
wall collapses inward during inspiration and balloons outward during expiration (paradoxical movement). The patient may have ecchymoses, severe localized pain, or other signs of traumatic injury to the chest wall. He may also exhibit rapid, shallow respirations, tachycardia, and cyanosis. Bleeding into the pleural space causes chest lag during inspiration in hemothorax, a life-threatening condition. Other findings include signs of traumatic chest injury, stabbing pain at the injury site, anxiety, dullness on percussion, tachypnea, tachycardia, and hypoxemia. If hypovolemia occurs, you’ll note signs of shock, such as hypotension and a rapid, weak pulse.

Kyphoscoliosis.

Abnormal curvature of the thoracic spine in the anteroposterior direction (kyphosis) and the lateral direction (scoliosis) gradually compresses one lung and distends the other. This produces decreased chest wall movement on the compressed-lung side and expands the intercostal muscles during inspiration on the opposite side. It can also produce ineffective coughing, dyspnea, back pain, and fatigue.

Myasthenia gravis.

Progressive loss of ventilatory muscle function produces asynchrony of the chest and abdomen during inspiration (“abdominal paradox”), which can lead to the onset of acute respiratory distress. Typically, the patient’s shallow respirations and increased muscle weakness cause severe dyspnea, tachypnea and, possibly, apnea. With phrenic nerve dysfunction, the paralyzed hemidiaphragm fails to contract downward, causing asynchrony of the thorax and upper abdomen on the affected side during inspiration (“abdominal paradox”). Its onset may be sudden, as in trauma, or gradual, as in infection or spinal cord disease. If the patient has underlying pulmonary dysfunction that contributes to hyperventilation, his inability to breathe deeply or to cough effectively may cause atelectasis of the affected lung.

Pleural effusion.

Chest lag at end-inspiration occurs gradually in pleural effusion — a life-threatening accumulation of fluid, blood, or pus in the pleural space. Usually, some combination of dyspnea, tachypnea, and tachycardia precedes chest lag; the patient may also have pleuritic pain that worsens with coughing or deep breathing. The area of the effusion is delineated by dullness on percussion and by egophony, bronchophony, whispered pectoriloquy, decreased or absent breath sounds, and decreased tactile fremitus. Fever appears if infection causes the effusion. Depending on whether fluid consolidation in the lungs develops unilaterally or bilaterally, asymmetrical chest expansion occurs as inspiratory chest lag or as chest-abdomen asynchrony. The patient typically has fever, chills, tachycardia, tachypnea, and dyspnea along with crackles, rhonchi, and chest pain that worsens during deep breathing. He may also be fatigued and anorexic and have a productive cough with green or yellow mucus or rust-colored sputum. Entrapment of air in the pleural space can cause chest lag at end-inspiration. Pneumothorax is a life-threatening condition that also causes sudden, stabbing chest pain that may radiate to the arms, face, back, or abdomen and dyspnea unrelated to the chest pain’s severity. Other findings include tachypnea, decreased tactile fremitus, tympany on percussion, decreased or absent breath sounds over the trapped air, tachycardia, restlessness, and anxiety.

With tension pneumothorax, the same signs and symptoms occur as in pneumothorax, but they’re much more severe. A tension pneumothorax rapidly compresses the heart and great vessels, causing cyanosis, hypotension, tachycardia, restlessness, and anxiety. The patient may also develop subcutaneous crepitation of the upper trunk, neck, and face and mediastinal and tracheal deviation away from the affected side. You may auscultate a crunching sound over the precordium with each heartbeat; this indicates pneumomediastinum.

Poliomyelitis.

With poliomyelitis — a rare disorder — paralysis of the chest wall muscles and diaphragm produces chest-abdomen asynchrony (“abdominal paradox”), fever, muscle pain, and weakness. Other findings include decreased reflex response in the affected muscles and impaired swallowing and speaking. Pulmonary embolism is an acute, life-threatening disorder that causes chest lag; sudden, stabbing chest pain; and tachycardia. The patient usually has severe dyspnea, blood-tinged sputum, pleural friction rub, and acute anxiety.

Other causes

Medical treatments.

Asymmetrical chest expansion can result from pneumonectomy and surgical removal of several ribs. Chest lag or the absence of chest movement may also result from intubation of a mainstem bronchus, a serious complication typically due to incorrect insertion of an endotracheal tube or tube movement while it’s in the trachea.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Flank pain: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

See Flank pain: Causes and associated findings, pages 152 and 153.

Bladder cancer

Dull, constant flank pain may be unilateral or bilateral and may radiate to the leg, back, and perineum. Commonly, the first sign of this cancer is gross, painless, intermittent hematuria, often with clots. Related effects may include urinary frequency and urgency, nocturia, dysuria, or pyuria; bladder distention; pain in the bladder, rectum, pelvis, back, or legs; diarrhea; vomiting; and sleep disturbances.

Calculi

Renal and ureteral calculi produce intense unilateral, colicky flank pain. Typically, initial CVA pain radiates to the flank, suprapubic region, and perhaps the genitalia; abdominal and lower back pain are also possible. Nausea and vomiting often accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, low-grade fever, and tenesmus).

Cortical necrosis (acute)

Unilateral flank pain is usually severe. Accompanying findings include gross hematuria, anuria, leukocytosis, and fever.

Cystitis (bacterial)

Unilateral or bilateral flank pain occurs secondarily to an ascending UTI. The patient may also report perineal, low back, and suprapubic pain. Other effects include dysuria, nocturia, hematuria, urinary frequency and urgency, tenesmus, fatigue, and low-grade fever.

Glomerulonephritis (acute)

Flank pain in patients with glomerulonephritis is bilateral, constant, and of moderate intensity. The most common findings are moderate facial and generalized edema, hematuria, oliguria or anuria, and fatigue. Other effects include slightly increased blood pressure, low-grade fever, malaise, headache, nausea, and vomiting. Accompanying signs of pulmonary congestion include dyspnea, tachypnea, and crackles.

Obstructive uropathy

With acute obstruction, flank pain may be excruciating; with gradual obstruction, it’s typically a dull ache. With both, the pain may also localize in the upper abdomen and radiate to the groin. Nausea and vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and hypoactive bowel sounds may also occur. Additional findings — a palpable abdominal mass, CVA tenderness, and bladder distention — vary with the site and cause of the obstruction.

Pancreatitis (acute)

Bilateral flank pain may develop as severe epigastric or left-upper-quadrant pain radiates to the back. A severe attack causes extreme pain, nausea and persistent vomiting, abdominal tenderness and rigidity, hypoactive bowel sounds and, possibly, restlessness, low-grade fever, tachycardia, hypotension, and positive Turner’s and Cullen’s signs.

Papillary necrosis (acute)

Intense bilateral flank pain occurs along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms include oliguria or anuria, hematuria, and pyuria, with associated high fever, chills, vomiting, and hypoactive bowel sounds.

Perirenal abscess

Intense unilateral flank pain and CVA tenderness accompany dysuria, persistent high fever, chills and, in some patients, a palpable abdominal mass.

Polycystic kidney disease

Dull, aching, bilateral flank pain is commonly the earliest symptom of polycystic kidney disease — a renal disorder. The pain can become severe and colicky if cysts rupture and clots migrate or cause obstruction. Nonspecific early findings include polyuria, increased blood pressure, and signs of UTI. Later findings include hematuria and perineal, low back, and suprapubic pain.

Pyelonephritis (acute)

Intense, constant, unilateral or bilateral flank pain develops over a few hours or days along with typical urinary features: dysuria, nocturia, hematuria, urgency, frequency, and tenesmus. Other common findings include persistent high fever, chills, anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness.

Renal cancer

Unilateral flank pain, gross hematuria, and a palpable flank mass form the classic clinical triad. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease.

Renal infarction

Unilateral, constant, severe flank pain and tenderness typically accompany persistent, severe upper abdominal pain. The patient may also develop CVA tenderness, anorexia, nausea and vomiting, fever, hypoactive bowel sounds, hematuria, and oliguria or anuria.

Renal trauma

Variable bilateral or unilateral flank pain is a common symptom. A visible or palpable flank mass may also exist, along with CVA or abdominal pain — which may be severe and radiate to the groin. Other findings include hematuria, oliguria, abdominal distention, Turner’s sign, hypoactive bowel sounds, and nausea or vomiting. Severe injury may produce signs of shock, such as tachycardia and cool, clammy skin.

Renal vein thrombosis

Severe unilateral flank and low back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms (nausea, vomiting, and uremic fetor) typify bilateral obstruction.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Chest pain: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

See Chest pain: Causes and associated findings, pages 78 to 81.

Angina pectoris.

With angina pectoris, the patient may experience a feeling of tightness or pressure in the chest that he describes as pain or a sensation of indigestion or expansion. The pain usually occurs in the retrosternal region over a palm-sized or larger area. It may radiate to the neck, jaw, and arms — classically, to the inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, and then slowly subside. Provoked by exertion, emotional stress, or a heavy meal, the pain typically lasts 2 to 10 minutes, usually no longer than 20 minutes. Associated findings include dyspnea, nausea, vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations. You may hear an atrial gallop (a fourth heart sound) or murmur during an anginal episode.

With Prinzmetal’s angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest — or it may awaken him. It may be accompanied by shortness of breath, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop. Anthrax is an acute infectious disease that’s caused by the gram-positive, spore-forming bacterium Bacillus anthracis. Although the disease most commonly occurs in wild and domestic grazing animals, such as cattle, sheep, and goats, the spores can live in the soil for many years. The disease can occur in humans exposed to infected animals, tissue from infected animals, or biological warfare. Most natural cases occur in agricultural regions worldwide, and it may occur in cutaneous, inhalation, and GI forms.

Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening. Acute anxiety — or, more commonly, panic attacks — can produce intermittent, sharp, stabbing pain, commonly located behind the left breast. This pain isn’t related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia — fear of leaving home or being in open places with other people.

Aortic aneurysm (dissecting).

The chest pain associated with aortic aneurysm — a life-threatening disorder — usually begins suddenly and is most severe at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest and neck that radiates to his upper back, abdomen, and lower back. He may exhibit abdominal tenderness, a palpable abdominal mass, tachycardia, murmurs, syncope, blindness, loss of consciousness, weakness or transient paralysis of the arms or legs, a systolic bruit, systemic hypotension, asymmetrical brachial pulses, lower blood pressure in the legs than in the arms, and weak or absent femoral or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid arteries.

Asthma.

In a life-threatening asthma attack, diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related respiratory findings include rhonchi, crackles, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, and tachypnea. The patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.

Blastomycosis.

Besides pleuritic chest pain, blastomycosis initially produces signs and symptoms that mimic those of viral upper respiratory tract infection: a dry, hacking, or productive cough (and sometimes hemoptysis), fever, chills, anorexia, weight loss, fatigue, night sweats, and malaise. In its acute form, bronchitis produces burning chest pain or a sensation of substernal tightness. It also produces a cough, initially dry but later productive, that worsens the chest pain. Other findings include low-grade fever, chills, sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101° to 102° F (38.3° to 38.9° C) and possible bronchospasm with worsening wheezing and increased coughing. With hypertrophic cardiomyopathy, angina-like chest pain may occur with dyspnea, cough, dizziness, syncope, gallops, murmurs, and bradycardia associated with tachycardia. Cholecystitis typically produces abrupt epigastric or right upper quadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may radiate to the back or right shoulder. Commonly associated findings include nausea, vomiting, fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an abdominal mass, rigidity, distention, or tenderness. Murphy’s sign — inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath — may also occur.

Coccidioidomycosis.

With coccidioidomycosis, pleuritic chest pain occurs with a dry or slightly productive cough. Other effects include fever, rhonchi, wheezing, occasional chills, sore throat, backache, headache, malaise, marked weakness, anorexia, and macular rash.

Costochondritis.

Pain and tenderness occur at the costochondral junctions, especially at the second costicartilage. The pain usually can be elicited by palpating the inflamed joint. Central chest pain may radiate to the left arm in patients with distention of colon’s splenic flexure. The pain may be relieved by defecation or passage of flatus. With esophageal spasm, substernal chest pain may last up to an hour and can radiate to the neck, jaw, arms, or back. It commonly mimics angina — a squeezing or dull sensation. Associated signs and symptoms include dysphagia for solid foods, bradycardia, and nodal rhythm. The pain of pre-eruptive herpes zoster may mimic that of an MI. Initially, the pain is characteristically sharp, shooting, and unilateral. About 4 to 5 days after its onset, small, red, nodular lesions erupt on the painful areas — usually the thorax, arms, and legs — and chest pain becomes burning. Associated findings include fever, malaise, pruritus, and paresthesia or hyperesthesia of the affected areas. Typically, hiatal hernia produces an angina-like sternal burning (heartburn), ache, or pressure that may radiate to the left shoulder and arm. The discomfort commonly occurs after a meal when the patient bends over or lies down. Other findings include a bitter taste and pain while eating or drinking, especially hot drinks and spicy foods. As interstitial lung disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.

Legionnaires’ disease.

Legionnaires’ disease produces pleuritic chest pain, in addition to malaise, headache and, possibly, diarrhea, anorexia, diffuse myalgia, and general weakness. Within 12 to 24 hours, the patient develops a sudden high fever, chills, and a nonproductive cough that progresses to mucoid and then to mucopurulent sputum, possibly with hemoptysis. Patients may also experience flushed skin, mild diaphoresis, prostration, nausea and vomiting, mild temporary amnesia, confusion, dyspnea, crackles, tachypnea, and tachycardia. Pleuritic chest pain develops insidiously in lung abscess along with a pleural friction rub and cough that raises copious amounts of purulent, foul-smelling, blood-tinged sputum. The affected side is dull on percussion, and decreased breath sounds and crackles may be heard. The patient also displays diaphoresis, anorexia, weight loss, fever, chills, fatigue, weakness, dyspnea, and clubbing.

Lung cancer.

The chest pain associated with lung cancer is commonly described as an intermittent aching felt deep within the chest. If the tumor metastasizes to the ribs or vertebrae, the pain becomes localized, continuous, and gnawing. Associated findings include cough (sometimes bloody), wheezing, dyspnea, fatigue, anorexia, weight loss, and fever.

Mediastinitis.

Mediastinitis produces severe retrosternal chest pain that radiates to the epigastrium, back, or shoulder and may worsen with breathing, coughing, or sneezing. Its accompanying signs and symptoms include chills, fever, and dysphagia.

Mitral valve prolapse.

Most patients with mitral valve prolapse are asymptomatic, but some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can last for seconds or hours and occasionally mimics the pain of ischemic heart disease. The characteristic sign of mitral prolapse is a midsystolic click followed by a systolic murmur at the apex. The patient may experience cardiac awareness, migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations. Strained chest, arm, or shoulder muscles may cause a superficial and continuous ache or “pulling” sensation in the chest. Lifting, pulling, or pushing heavy objects may aggravate this discomfort. With acute muscle strain, the patient may experience fatigue, weakness, and rapid swelling of the affected area.

Myocardial infarction (MI).

The chest pain during an MI lasts from 15 minutes to hours. Typically, crushing substernal pain, unrelieved by rest or nitroglycerin, may radiate to the patient’s left arm, jaw, neck, or shoulder blades. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, atrial gallop, murmurs, and crackles. Nocardiosis causes pleuritic chest pain with a cough that produces thick, tenacious, purulent or mucopurulent, and possibly blood-tinged sputum. Nocardiosis may also cause fever, night sweats, anorexia, malaise, weight loss, and diminished or absent breath sounds. In the acute form, pancreatitis usually causes intense pain in the epigastric area that radiates to the back and worsens when the patient is in a supine position. Nausea, vomiting, fever, abdominal tenderness and rigidity, diminished bowel sounds, and crackles at the lung bases may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes massive hemorrhage, resulting in shock and coma.

Peptic ulcer.

With peptic ulcer, sharp and burning pain usually arises in the epigastric region. This pain characteristically arises hours after food intake, commonly during the night. It lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood), melena, and epigastric tenderness. Pericarditis produces precordial or retrosternal pain aggravated by deep breathing, coughing, position changes, and occasionally by swallowing. The pain is commonly sharp or cutting and radiates to the shoulder and neck. Associated signs and symptoms include pericardial friction rub, fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered. Plague is an acute bacterial infection caused by Yersinia pestis. It’s one of the most virulent infections and, if untreated, one of the most potentially lethal diseases known. Most cases are sporadic, but the potential for epidemic spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted to man when bitten by infected fleas. Signs and symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the fleabite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The pneumonic form may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, fever, headache, and myalgia. Pulmonary signs and symptoms include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency. The chest pain of pleurisy arises abruptly and reaches maximum intensity within a few hours. The pain is sharp, even knifelike, usually unilateral, and located in the lower and lateral aspects of the chest. Deep breathing, coughing, or thoracic movement characteristically aggravates it. Auscultation over the painful area may reveal decreased breath sounds, inspiratory crackles, and a pleural friction rub. Dyspnea, rapid, shallow breathing, cyanosis, fever, and fatigue may also occur. Pneumonia produces pleuritic chest pain that increases with deep inspiration and is accompanied by shaking chills and fever. The patient has a dry cough that later becomes productive. Other signs and symptoms include crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis. Spontaneous pneumothorax, a life-threatening disorder, causes sudden sharp chest pain that’s severe, typically unilateral, and rarely localized; it increases with chest movement. When the pain is centrally located and radiates to the neck, it may mimic that of an MI. After the pain’s onset, dyspnea and cyanosis progressively worsen. Breath sounds are decreased or absent on the affected side with hyperresonance or tympany, subcutaneous crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory muscle use, nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.

Psittacosis.

Psittacosis may produce pleuritic chest pain on rare occasions. It typically begins abruptly with chills, fever, headache, myalgia, epistaxis, and prostration. Pulmonary actinomycosis causes pleuritic chest pain with a cough that’s initially dry but later produces purulent sputum. The patient may also display hemoptysis, fever, weight loss, fatigue, weakness, dyspnea, and night sweats. Multiple sinuses may extend through the chest wall and drain externally. Pulmonary embolism produces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain aggravated by deep breathing and thoracic movement. Other findings include tachycardia, tachypnea, cough (nonproductive or producing blood-tinged sputum), low-grade fever, restlessness, diaphoresis, crackles, pleural friction rub, diffuse wheezing, dullness on percussion, signs of circulatory collapse (weak, rapid pulse; hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness, coma, seizures), signs of hypoxia (restlessness) and, particularly in the elderly, hemiplegia and other focal neurologic deficits. Less common signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and jugular vein distention. Angina-like pain develops late in patients with pulmonary hypertension, usually on exertion. The precordial pain may radiate to the neck but doesn’t characteristically radiate to the arms. Typical accompanying signs and symptoms include exertional dyspnea, fatigue, syncope, weakness, cough, and hemoptysis. Q fever is a Rickettsial disease caused by Coxiella burnetii. The primary source of human infection results from exposure to infected animals. Cattle, sheep, and goats are most likely to carry the organism. Human infection results from exposure to contaminated milk, urine, feces, or other fluids from infected animals. Infection may also result from inhalation of contaminated barnyard dust. C. burnetii is highly infectious and is considered a possible airborne agent for biological warfare. Signs and symptoms include fever, chills, severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last for up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia. The chest pain due to fractured ribs is usually sharp, severe, and aggravated by inspiration, coughing, or pressure on the affected area. Besides shallow, splinted respirations, dyspnea, and cough, the patient experiences tenderness and slight edema at the fracture site. Chest pain associated with sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain worsens, it becomes generalized or localized to the abdomen or chest, causing severe pleuritic pain. The presence of chest pain and difficulty breathing requires prompt intervention. The patient may also have abdominal distention and rigidity, dyspnea, fever, and jaundice. Commonly causing paresthesia along the ulnar distribution of the arm, thoracic outlet syndrome can be confused with angina, especially when it affects the left arm. The patient usually experiences angina-like pain after lifting his arms above his head, working with his hands above his shoulders, or lifting a weight. The pain disappears as soon as he lowers his arms. Other signs and symptoms include pale skin and a difference in blood pressure between both arms. In a patient with tuberculosis, pleuritic chest pain and fine crackles occur after coughing. Associated signs and symptoms include night sweats, anorexia, weight loss, fever, malaise, dyspnea, easy fatigability, mild to severe productive cough, occasional hemoptysis, dullness on percussion, increased tactile fremitus, and amphoric breath sounds. Also known as rabbit fever, tularemia is caused by the gram-negative, non-spore forming bacterium Francisella tularensis. It’s typically a rural disease found in wild animals, water, and moist soil. It’s transmitted to humans through the bite of an infected insect or tick, handling infected animal carcasses, drinking contaminated water, or inhaling the bacteria. It’s considered a possible airborne agent for biological warfare. Signs and symptoms following inhalation of the organism include the abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Chinese restaurant syndrome, which stems from a reaction to excessive ingestion of monosodium glutamate (a common additive in Chinese foods), is a benign condition that mimics the signs of an acute MI. The patient may complain of retrosternal burning, ache, or pressure; a burning sensation over his arms, legs, and face; a sensation of facial pressure; headache; shortness of breath; and tachycardia.

Drugs.

Abrupt withdrawal of a beta-adrenergic blocker can cause rebound angina if the patient has coronary heart disease — especially if he has received high doses for a prolonged period.

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Chest expansion, asymmetrical: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Bronchial obstruction

With bronchial obstruction, life-threatening loss of airway patency may occur gradually or suddenly. Typically, lack of chest movement indicates complete obstruction; chest lag signals partial obstruction. If air is trapped in the chest, you may detect intercostal bulging during expiration and hyperresonance on percussion. You may also note dyspnea, accessory muscle use, decreased or absent breath sounds, and suprasternal, substernal, or intercostal retractions.

Flail chest

With flail chest, a life-threatening injury to the ribs or sternum, the unstable portion of the chest wall collapses inward during inspiration and balloons outward during expiration (paradoxical movement). The patient may have ecchymoses, severe localized pain, or other signs of traumatic injury to the chest wall. He may also exhibit rapid, shallow respirations, tachycardia, and cyanosis.

Hemothorax

Hemothorax, life-threatening bleeding into the pleural space, causes chest lag during inspiration. Other findings include signs of traumatic chest injury, stabbing pain at the injury site, anxiety, dullness on percussion, tachypnea, tachycardia, and hypoxemia. If hypovolemia occurs, you’ll note signs of shock, such as hypotension and rapid, weak pulse.

Kyphoscoliosis

Abnormal curvature of the thoracic spine in the anteroposterior direction (kyphosis) and the lateral direction (scoliosis) gradually compresses one lung and distends the other causing kyphoscoliosis. This produces decreased chest wall movement on the compressed-lung side and expands the intercostal muscles during inspiration on the opposite side. It can also produce ineffective coughing, dyspnea, back pain, and fatigue.

Myasthenia gravis

With myasthenia gravis, progressive loss of ventilatory muscle function produces asynchrony of the chest and abdomen during inspiration (“abdominal paradox”), which can lead to the onset of acute respiratory distress. Typically, the patient’s shallow respirations and increased muscle weakness cause severe dyspnea, tachypnea, and possible apnea.

Phrenic nerve dysfunction

With phrenic nerve dysfunction, the paralyzed hemidiaphragm fails to contract downward, causing asynchrony of the thorax and upper abdomen on the affected side during inspiration (“abdominal paradox”). Its onset may be sudden, as in trauma, or gradual, as in infection or spinal cord disease. If the patient has underlying pulmonary dysfunction that contributes to hyperventilation, his inability to breathe deeply or to cough effectively may cause atelectasis of the affected lung.

Pleural effusion

Chest lag at end-inspiration occurs gradually in pleural effusion, a life-threatening accumulation of fluid, blood, or pus in the pleural space. Usually, some combination of dyspnea, tachypnea, and tachycardia precedes chest lag; the patient may also have pleuritic pain that worsens with coughing or deep breathing. The area of the effusion is delineated by dullness on percussion and by egophony, bronchophony, whispered pectoriloquy, decreased or absent breath sounds, and decreased tactile fremitus. Fever appears if infection causes the effusion.

Pneumonia

Depending on whether fluid consolidation in the lungs develops unilaterally or bilaterally with pneumonia, asymmetrical chest expansion occurs as inspiratory chest lag or as chest-abdomen asynchrony. The patient typically has fever, chills, tachycardia, tachypnea, and dyspnea along with crackles, rhonchi, and chest pain that worsens during deep breathing. He may also be fatigued and anorexic and have a productive cough with rust-colored sputum.

Pneumothorax

Pneumothorax, the entrapment of air in the pleural space, can cause chest lag at end-inspiration. This life-threatening condition also causes sudden, stabbing chest pain that may radiate to the arms, face, back, or abdomen and dyspnea unrelated to the chest pain’s severity. Other findings include tachypnea, decreased tactile fremitus, tympany on percussion, decreased or absent breath sounds over the trapped air, tachycardia, restlessness, and anxiety.

With tension pneumothorax, the same signs and symptoms occur as in pneumothorax, but they’re much more severe. A tension pneumothorax rapidly compresses the heart and great vessels, causing cyanosis, hypotension, tachycardia, restlessness, and anxiety. The patient may also develop subcutaneous crepitation of the upper trunk, neck, and face and mediastinal and tracheal deviation away from the affected side. You may auscultate a crunching sound over the precordium with each heartbeat; this indicates pneumomediastinum.

Other causes

Treatments

Asymmetrical chest expansion can result from treatments such as pneumonectomy and the surgical removal of several ribs. Chest lag or the absence of chest movement may also result from intubation of a mainstem bronchus, a serious complication typically due to incorrect insertion of an endotracheal tube or movement of the tube while it’s in the trachea.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Flank pain: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Bladder cancer

With bladder cancer, dull, constant flank pain may be unilateral or bilateral and may radiate to the leg, back, and perineum. Commonly, the first sign of this cancer is gross, painless, intermittent hematuria, usually with clots. Related effects may include urinary frequency and urgency, nocturia, dysuria, or pyuria; bladder distention; pain in the bladder, rectum, pelvis, back, or legs; diarrhea; vomiting; and sleep disturbances.

Calculi

Renal and ureteral calculi produce intense unilateral, colicky flank pain. Typically, initial CVA pain radiates to the flank, suprapubic region, and perhaps the genitalia; abdominal and lower back pain are also possible. Nausea and vomiting usually accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, low-grade fever, and tenesmus).

Cystitis (bacterial)

Unilateral or bilateral flank pain occurs secondarily to an ascending UTI. The patient with bacterial cystitis may also report perineal, low back, and suprapubic pain. Other effects include dysuria, nocturia, hematuria, urinary frequency and urgency, tenesmus, fatigue, and low-grade fever.

Glomerulonephritis (acute)

Flank pain in acute glomerulonephritis is bilateral, constant, and moderately intense. The most common findings are moderate facial and generalized edema, hematuria, oliguria or anuria, and fatigue. Other effects include slightly increased blood pressure, low-grade fever, malaise, headache, nausea, and vomiting. Accompanying signs of pulmonary congestion include dyspnea, tachypnea, and crackles.

Obstructive uropathy

With acute obstruction, flank pain may be excruciating; with gradual obstruction, it’s typically a dull ache. With both, the pain may also localize in the upper abdomen and radiate to the groin. Nausea and vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and hypoactive bowel sounds may also occur. Additional findings — a palpable abdominal mass, CVA tenderness, and bladder distention — vary with the site and cause of the obstruction.

Pancreatitis (acute)

Bilateral flank pain may develop in patients with acute pancreatitis as severe epigastric or left-upper-quadrant pain radiates to the back. A severe attack causes extreme pain, nausea and persistent vomiting, abdominal tenderness and rigidity, hypoactive bowel sounds and, possibly, restlessness, low-grade fever, tachycardia, hypotension, and positive Turner’s and Cullen’s signs.

Papillary necrosis (acute)

Intense bilateral flank pain occurs along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms of acute papillary necrosis include oliguria or anuria, hematuria, and pyuria, with associated high fever, chills, vomiting, and hypoactive bowel sounds.

Perirenal abscess

With a perirenal abscess, intense unilateral flank pain and CVA tenderness accompany dysuria, persistent high fever, chills and, in some patients, a palpable abdominal mass.

Polycystic kidney disease

Dull, aching, bilateral flank pain is commonly the earliest symptom of polycystic kidney disease. The pain can become severe and colicky if cysts rupture and clots migrate or cause obstruction. Nonspecific early findings include polyuria, increased blood pressure, and signs of UTI. Later findings include hematuria and perineal, low back, and suprapubic pain.

Pyelonephritis (acute)

With acute pyelonephritis, intense, constant, unilateral or bilateral flank pain develops over a few hours or days along with typical urinary features: dysuria, nocturia, hematuria, urgency, frequency, and tenesmus. Other common findings in acute pyelonephritis include persistent high fever, chills, anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness.

Renal cancer

Unilateral flank pain, gross hematuria, and a palpable flank mass form the classic clinical triad in patients with renal cancer. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease.

Renal infarction

With renal infarction, unilateral, constant, severe flank pain and tenderness typically accompany persistent, severe upper abdominal pain. The patient may also develop CVA tenderness, anorexia, nausea and vomiting, fever, hypoactive bowel sounds, hematuria, and oliguria or anuria.

Renal trauma

Variable bilateral or unilateral flank pain is a common symptom of renal trauma. A visible or palpable flank mass may also exist, along with CVA or abdominal pain — which may be severe and radiate to the groin. Other findings include hematuria, oliguria, abdominal distention, Turner’s sign, hypoactive bowel sounds, and nausea or vomiting. Severe injury may produce signs of shock, such as tachycardia and cool, clammy skin.

Renal vein thrombosis

Severe unilateral flank and low back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms (nausea, vomiting, and uremic fetor) typify bilateral obstruction.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Chest pain: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Angina pectoris

With angina pectoris, the patient may experience a feeling of tightness or pressure in the chest that he describes as pain or a sensation of indigestion or expansion. The pain usually occurs in the retrosternal region. It may radiate to the neck, jaw, and arms — classically, to the inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, then slowly subside. Provoked by exertion, emotional stress, or a heavy meal, the pain typically lasts 2 to 10 minutes (usually no longer than 20 minutes). Associated findings include dyspnea, nausea, vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations. You may hear an atrial gallop (a fourth heart sound [S 4]) or murmur during an anginal episode.

CULTURAL CUE:Not all patients experience angina in the same way. For example, Black and Hispanic patients may not feel chest discomfort. Primary symptoms among these populations may include dyspnea and fatigue.

With Prinzmetal’s angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest — or it may awaken him. It may be accompanied by shortness of breath, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop.

Anthrax (inhalation)

Inhalation anthrax is caused by inhalation of aerosolized spores of the gram-positive bacterium Bacillus anthracis. Initial signs and symptoms are flulike and include fever, chills, weakness, cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Anxiety

Acute anxiety — or, more commonly, panic attacks — can produce intermittent, sharp, stabbing pain, commonly located behind the left breast. This pain isn’t related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia — fear of leaving home or being in open places with other people.

Aortic aneurysm (dissecting)

The chest pain associated with dissecting aortic aneurysm (a life-threatening disorder) usually begins suddenly and is most severe at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest and neck that radiates to his upper back, abdomen, and lower back. He may also have abdominal tenderness; a palpable abdominal mass; tachycardia; murmurs; syncope; blindness; loss of consciousness; weakness or transient paralysis of the arms or legs; a systolic bruit; systemic hypotension; asymmetrical brachial pulses; lower blood pressure in the legs than in the arms; and weak or absent femoral or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid arteries.

Asthma

In a life-threatening asthma attack, diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related respiratory findings include rhonchi, crackles, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, and tachypnea. The patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.

Bronchitis

In its acute form, bronchitis produces a burning chest pain or a sensation of substernal tightness. It also produces a cough, initially dry but later productive, that worsens the chest pain. Other findings include a low-grade fever, chills, sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101° to 102° F (38.3° to 38.9° C) and possible bronchospasm with worsening wheezing and increased coughing.

Cardiomyopathy

With hypertrophic cardiomyopathy, angina-like chest pain may occur with dyspnea, a cough, dizziness, syncope, gallops, murmurs, and bradycardia associated with tachycardia. The patient may have a medium-pitched systolic ejection murmur along the left sternal border and apex of the heart. Palpation of peripheral pulses reveals a characteristic double impulse (pulsus biferiens and, with atrial fibrillation, an irregular pulse).

Cholecystitis

Cholecystitis typically produces abrupt epigastric or right-upper-quadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may radiate to the back or the right shoulder. Common associated findings include nausea, vomiting, fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an abdominal mass, rigidity, distention, or tenderness. Murphy’s sign — inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath — may also occur.

Costochondritis

With costochondritis, pain and tenderness occur at the costochondral junctions, especially at the second costicartilage. The pain usually can be elicited by palpating the inflamed joint. It may be described as a sharp pain in the chest wall that worsens with movement.

Distention of colon’s splenic flexure

Central chest pain may radiate to the left arm in patients with distention of the colon’s splenic flexure. The pain may be relieved by defecation or the passage of flatus. Other signs and symptoms include fever, tachycardia, abdominal pain, and palpable abdominal mass.

Esophageal spasm

With esophageal spasm, substernal chest pain may last up to an hour and can radiate to the neck, jaw, arms, or back. It tends to mimic angina — a squeezing or dull sensation. Associated signs and symptoms include dysphagia for solid foods, bradycardia, and nodal rhythm.

Herpes zoster (shingles)

The pain of preeruptive herpes zoster may mimic that of myocardial infarction (MI). Initially, the pain is characteristically sharp, shooting, and unilateral. About 4 to 5 days after its onset, small, red, nodular lesions erupt on the painful areas — usually the thorax, arms, and legs — and the chest pain becomes burning. Associated findings include fever, malaise, pruritus, and paresthesia or hyperesthesia of the affected areas.

Hiatal hernia

Typically, hiatal hernia produces an angina-like sternal burning (heartburn), ache, or pressure that may radiate to the left shoulder and arm. The discomfort commonly occurs after a meal when the patient bends over or lies down. Other findings include a bitter taste and pain while eating or drinking, especially hot drinks and spicy foods.

Interstitial lung disease

As interstitial lung disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.

Legionnaires’ disease

Legionnaires’ disease produces pleuritic chest pain in addition to malaise, headache and, possibly, diarrhea, anorexia, diffuse myalgia, and general weakness. Within 12 to 24 hours, the patient develops a sudden high fever, chills, and a nonproductive cough that progresses to mucoid and then to mucopurulent sputum, possibly with hemoptysis. Patients may also experience flushed skin, mild diaphoresis, prostration, nausea and vomiting, mild temporary amnesia, confusion, dyspnea, crackles, tachypnea, and tachycardia.

Mediastinitis

Mediastinitis produces severe retrosternal chest pain that radiates to the epigastrium, back, or shoulder and may worsen with breathing, coughing, or sneezing. Its accompanying signs and symptoms include chills, fever, and dysphagia.

Mitral valve prolapse

Most patients with mitral valve prolapse are asymptomatic, but some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can last for seconds or for hours, and occasionally mimics the pain of ischemic heart disease. The characteristic sign of mitral valve prolapse is a midsystolic click followed by a systolic murmur at the apex. The patient may experience cardiac awareness, migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations.

Muscle strain

Strained chest, arm, or shoulder muscles may cause a superficial and continuous ache or “pulling” sensation in the chest. Lifting, pulling, or pushing heavy objects may aggravate this discomfort. With acute muscle strain, the patient may experience fatigue, weakness, and rapid swelling of the affected area.

Myocardial infarction

The chest pain during an MI lasts from 15 minutes to hours. Typically a crushing substernal pain, unrelieved by rest or nitroglycerin, it may radiate to the patient’s left arm, jaw, neck, or shoulder blades. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, an atrial gallop, murmurs, and crackles.

Pancreatitis

In the acute form, pancreatitis usually causes intense pain in the epigastric area that radiates to the back and worsens when the patient is in a supine position. Nausea, vomiting, fever, abdominal tenderness and rigidity, diminished bowel sounds, and crackles at the lung bases may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes massive hemorrhage, resulting in shock and coma.

Peptic ulcer

With a peptic ulcer, sharp and burning pain usually arises in the epigastric region. This pain characteristically arises hours after food intake, commonly during the night. It lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood), melena, and epigastric tenderness.

Pericarditis

Pericarditis produces precordial or retrosternal pain aggravated by deep breathing, coughing, position changes, and occasionally by swallowing. The pain is commonly sharp or cutting and radiates to the shoulder and neck. Associated signs and symptoms include pericardial friction rub, fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered.

Plague

The pneumonic form of plague, caused by the bacterium Yersinia pestis, is characterized by a sudden onset of chills, fever, headache, and myalgia. Pulmonary signs and symptoms include productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress and cardiopulmonary insufficiency.

Pleurisy

The chest pain of pleurisy arises abruptly and reaches maximum intensity within a few hours. The pain is sharp, even knifelike, usually unilateral, and located in the lower and lateral aspects of the chest. Deep breathing, coughing, or thoracic movement characteristically aggravates it. Auscultation over the painful area may reveal decreased breath sounds, inspiratory crackles, and a pleural friction rub. Dyspnea, rapid, shallow breathing, cyanosis, fever, and fatigue may also occur.

Pneumonia

Pneumonia produces pleuritic chest pain that increases with deep inspiration and is accompanied by shaking chills and fever. The patient has a dry cough that later becomes productive. Other signs and symptoms include crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis.

Pneumothorax

Spontaneous pneumothorax, a life-threatening disorder, causes sudden sharp chest pain that’s severe, typically unilateral, and rarely localized; it increases with chest movement. When the pain is centrally located and radiates to the neck, it may mimic that of an MI. After the pain’s onset, dyspnea and cyanosis progressively worsen. Breath sounds are decreased or absent on the affected side with hyperresonance or tympany, subcutaneous crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory muscle use, a nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.

Pulmonary embolism

Pulmonary embolism produces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain aggravated by deep breathing and thoracic movement. Other findings include tachycardia, tachypnea, cough (nonproductive or producing blood-tinged sputum), low-grade fever, restlessness, diaphoresis, crackles, pleural friction rub, diffuse wheezing, dullness to percussion, signs of circulatory collapse (weak, rapid pulse; hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness, coma, seizures), signs of hypoxia (restlessness) and, particularly in the elderly, hemiplegia and other focal neurologic deficits. Less common signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and distended neck veins.

Pulmonary hypertension (primary)

Angina-like pain develops late in patients with primary pulmonary hypertension, usually on exertion. The precordial pain may radiate to the neck but doesn’t characteristically radiate to the arms. Typical accompanying signs and symptoms include exertional dyspnea, fatigue, syncope, weakness, cough, and hemoptysis.

Q fever

Signs and symptoms of Q fever, a rickettsial disease caused by Coxiella burnetti, include fever, chills, severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Rib fracture

The chest pain due to fractured ribs is usually sharp, severe, and aggravated by inspiration, coughing, or pressure on the affected area. Besides shallow, splinted respirations, dyspnea, and cough, the patient experiences tenderness and slight edema at the fracture site.

Sickle cell crisis

Chest pain associated with sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain worsens, it becomes generalized or localized to the abdomen or chest, causing severe pleuritic pain. The presence of chest pain and difficulty breathing requires prompt intervention. The patient may also have abdominal distention and rigidity, dyspnea, fever, and jaundice.

Tuberculosis

In a patient with tuberculosis, pleuritic chest pain and fine crackles occur after coughing. Associated signs and symptoms include night sweats, anorexia, weight loss, fever, malaise, dyspnea, easy fatigability, mild to severe productive cough, occasional hemoptysis, dullness to percussion, increased tactile fremitus, and amphoric breath sounds.

Tularemia

Following inhalation of the gram-negative, non-spore-forming bacterium Francisella tularensis, patients with tularemia show signs and symptoms that include the abrupt onset of fever, chills, headache, generalized myalgia, nonproductive cough, dyspnea, and empyema. Pneumonia can develop, causing chest pain and hemoptysis.

Other causes

Chinese restaurant syndrome

This benign condition — a reaction to excessive ingestion of monosodium glutamate, a common additive in Chinese foods — mimics the signs of an acute MI. The patient may complain of retrosternal burning, ache, or pressure; a burning sensation over his arms, legs, and face; a sensation of facial pressure; headache; shortness of breath; and tachycardia.

Drugs

Abrupt withdrawal of a beta-adrenergic blocker can cause rebound angina if the patient has coronary heart disease — especially if he has received high doses for a prolonged period.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Chest Pain: Principal Causes of Chest Pain
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

  1. Musculoskeletaldisorders
    1. Muscle
      1. Trauma(strain, contusion, laceration)
      2. Stitch
      3. Precordial catch
      4. Sickle cell pain episodes
    2. Bone/cartilage
      1. Trauma(contusion, rib fracture)
      2. Costochondritis
      3. Sickle cell pain episodes
      4. Slipping-rib syndrome
      5. Tietze syndrome
      6. Osteomyelitis
      7. Neoplasm
  2. Trachea and proximal bronchi disorders
    1. Infection/inflammation
      1. Bronchitis
      2. Tracheitis
      3. Pneumonia
      4. Cystic fibrosis
    2. Asthma
    3. Foreign body
  3. Parietal pleura disorders
    1. Pneumonia
    2. Pleurodynia
    3. Empyema
    4. Pneumothorax
    5. Hemothorax
    6. Pneumomediastinum
    7. Postpericardiotomy syndrome
    8. Pulmonary embolism
    9. Neoplasm
  4. Cardiac disorders
    1. Myocardialischemia including infarction
    2. Pericarditis
    3. Mitral valve prolapse
    4. Arrhythmias
  5. Diaphragm disorders
    1. Subphrenicabscess
    2. Hepatic abscess
    3. Fitz-Hugh-Curtis syndrome
  6. Gastrointestinal disorders
    1. Esophagus
      1. Gastroesophagealreflux
      2. Caustic ingestion
      3. Foreign body
      4. Hiatal hernia
      5. Spasm
      6. Tear
    2. Referred pain
      1. Gastritis
      2. Peptic ulcer disease
      3. Cholesystitis
      4. Pancreatitis
  7. Neurologic disorders
    1. Intercostalnerve
      1. Trauma
      2. Herpes zoster neuritis
    2. Dorsal root
      1. Trauma
      2. Radiculitis
  8. Psychologic disorders
    1. Anxietywith or without hyperventilation
    2. Depression
    3. School phobia
    4. Hypochondriasis
    5. Conversion reaction
  9. Idiopathic chest pain

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Chest expansion, asymmetrical: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Bronchial obstruction.With a bronchial obstruction, life-threatening loss of airway patency may occur gradually or suddenly. Typically, a lack of chest movement indicates complete obstruction; chest lag signals partial obstruction. If air is trapped in the chest, you may detect intercostal bulging during expiration and hyperresonance on percussion. You may also note dyspnea, accessory muscle use, decreased or absent breath sounds, and suprasternal, substernal, or intercostal retractions.

Flail chest.With flail chest, a life-threatening injury to the ribs or sternum, the unstable portion of the chest wall collapses inward during inspiration and balloons outward during expiration (paradoxical movement). The patient may have ecchymoses, severe localized pain, or other signs of traumatic injury to the chest wall. He may also exhibit rapid, shallow respirations, tachycardia, and cyanosis.

Hemothorax.Hemothorax is life-threatening bleeding into the pleural space that causes chest lag during inspiration. Other findings include signs of traumatic chest injury, stabbing pain at the injury site, anxiety, dullness on percussion, tachypnea, tachycardia, and hypoxemia. If hypovolemia occurs, you'll note signs of shock, such as hypotension and a rapid, weak pulse.

Kyphoscoliosis.Abnormal curvature of the thoracic spine in the anteroposterior direction (kyphosis) and the lateral direction (scoliosis) gradually compresses one lung and distends the other. This produces decreased chest wall movement on the compressed-lung side and expands the intercostal muscles during inspiration on the opposite side. It can also produce ineffective coughing, dyspnea, back pain, and fatigue.

Myasthenia gravis.With myasthenia gravis, progressive loss of ventilatory muscle function produces asynchrony of the chest and abdomen during inspiration (“abdominal paradox”), which can lead to the onset of acute respiratory distress. Typically, the patient's shallow respirations and increased muscle weakness cause severe dyspnea, tachypnea, and possible apnea.

Pleural effusion.Chest lag at end-inspiration occurs gradually in this life-threatening accumulation of fluid, blood, or pus in the pleural space. Usually, some combination of dyspnea, tachypnea, and tachycardia precedes chest lag; the patient may also have pleuritic pain that worsens with coughing or deep breathing. The area of the effusion is delineated by dullness on percussion and by egophony, bronchophony, whispered pectoriloquy, decreased or absent breath sounds, and decreased tactile fremitus. A fever appears if infection causes the effusion.

Pneumonia.Depending on whether fluid consolidation in the lungs develops unilaterally or bilaterally, asymmetrical chest expansion occurs with pneumonia, as inspiratory chest lag or as chest-abdomen asynchrony. The patient typically has a fever, chills, tachycardia, tachypnea, and dyspnea along with crackles, rhonchi, and chest pain that worsens during deep breathing. He may also be fatigued and anorexic and have a productive cough with rust-colored sputum.

Pneumothorax.Entrapment of air in the pleural space can cause chest lag at end-inspiration. Pneumothorax, a life-threatening condition, also causes sudden, stabbing chest pain that may radiate to the arms, face, back, or abdomen and dyspnea unrelated to the chest pain's severity. Other findings include tachypnea, decreased pulse oximetry, decreased tactile fremitus, tympany on percussion, decreased or absent breath sounds over the trapped air, tachycardia, restlessness, and anxiety.

With tension pneumothorax, the same signs and symptoms occur as in pneumothorax, but they're much more severe. Tension pneumothorax rapidly compresses the heart and great vessels, causing cyanosis, hypotension, decreased pulse oximetry, tachycardia, restlessness, and anxiety. The patient may also develop subcutaneous crepitation of the upper trunk, neck, and face and mediastinal and tracheal deviation away from the affected side. You may auscultate a crunching sound over the precordium with each heartbeat; this indicates pneumomediastinum.

Pulmonary embolism.Pulmonary embolism is an acute, life-threatening disorder that causes chest lag; sudden, stabbing chest pain; and tachycardia. The patient usually has severe dyspnea, blood-tinged sputum, a pleural friction rub, and acute anxiety.

Other causes

Treatments.Asymmetrical chest expansion can result from pneumonectomy and the surgical removal of several ribs. Chest lag or the absence of chest movement may also result from intubation of a mainstem bronchus, a serious complication typically due to the incorrect insertion of an endotracheal (ET) tube or movement of the tube while it's in the trachea.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Flank pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Calculi.Renal and ureteral calculi produce intense unilateral, colicky flank pain. Typically, initial CVA pain radiates to the flank, suprapubic region, and perhaps the genitalia; abdominal and lower back pain are also possible. Nausea and vomiting commonly accompany severe pain. Associated findings include CVA tenderness, hematuria, hypoactive bowel sounds and, possibly, signs and symptoms of a UTI (urinary frequency and urgency, dysuria, nocturia, fatigue, a low-grade fever, and tenesmus).

Cortical necrosis (acute).Unilateral flank pain is usually severe with corticol necrosis. Accompanying findings include gross hematuria, anuria, leukocytosis, and a fever.

Obstructive uropathy.With acute obstruction, flank pain may be excruciating; with gradual obstruction, it's typically a dull ache. With both, the pain may also localize in the upper abdomen and radiate to the groin. Nausea and vomiting, abdominal distention, anuria alternating with periods of oliguria and polyuria, and hypoactive bowel sounds may also occur. Additional findings—a palpable abdominal mass, CVA tenderness, and bladder distention—vary with the site and cause of the obstruction.

Papillary necrosis (acute).Intense bilateral flank pain occurs with papillary necrosis along with renal colic, CVA tenderness, and abdominal pain and rigidity. Urinary signs and symptoms include oliguria or anuria, hematuria, and pyuria, with associated high fever, chills, vomiting, and hypoactive bowel sounds.

Perirenal abscess.With perirenal abscess, intense unilateral flank pain and CVA tenderness accompany dysuria, a persistent high fever, chills and, in some patients, a palpable abdominal mass.

Polycystic kidney disease.Dull, aching, bilateral flank pain is commonly the earliest symptom of polycystic kidney disease. The pain can become severe and colicky if cysts rupture and clots migrate or cause obstruction. Nonspecific early findings include polyuria, increased blood pressure, and signs of a UTI. Later findings include hematuria and perineal, low back, and suprapubic pain.

Pyelonephritis (acute).Intense, constant, and unilateral or bilateral flank pain develops over a few hours or days with acute pyelonephritis along with typical urinary features: dysuria, nocturia, hematuria, urgency, frequency, and tenesmus. Other common findings include a persistent high fever, chills, anorexia, weakness, fatigue, generalized myalgia, abdominal pain, and marked CVA tenderness.

Renal cancer.Unilateral flank pain, gross hematuria, and a palpable flank mass form the classic clinical triad in renal cancer. Flank pain is usually dull and vague, although severe colicky pain can occur during bleeding or passage of clots. Associated signs and symptoms include a fever, increased blood pressure, and urine retention. Weight loss, leg edema, nausea, and vomiting are indications of advanced disease.

Renal infarction.Unilateral, constant, severe flank pain and tenderness typically accompany persistent, severe upper abdominal pain with renal infarction. The patient may also develop CVA tenderness, anorexia, nausea and vomiting, a fever, hypoactive bowel sounds, hematuria, and oliguria or anuria.

Renal trauma.Variable bilateral or unilateral flank pain is a common symptom of renal trauma. A visible or palpable flank mass may also exist, along with CVA or abdominal pain—which may be severe and radiate to the groin. Other findings include hematuria, oliguria, abdominal distention, Turner's sign, hypoactive bowel sounds, and nausea or vomiting. Severe injury may produce signs of shock, such as tachycardia and cool, clammy skin.

Renal vein thrombosis.Severe unilateral flank and lower back pain with CVA and epigastric tenderness typify the rapid onset of venous obstruction. Other features include a fever, hematuria, and leg edema. Bilateral flank pain, oliguria, and other uremic signs and symptoms (nausea, vomiting, and uremic fetor) typify bilateral obstruction.

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Source: Nursing: Interpreting Signs and Symptoms, 2007

Chest pain: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Angina pectoris.With angina pectoris, the patient may experience a feeling of tightness or pressure in the chest that he describes as pain or a sensation of indigestion or expansion. The pain usually occurs in the retrosternal region over a palm-sized or larger area. It may radiate to the neck, jaw, and arms—classically, to the inner aspect of the left arm. Angina tends to begin gradually, build to its maximum, and then slowly subside. Provoked by exertion, emotional stress, or a heavy meal, the pain typically lasts 2 to 10 minutes (usually no longer than 20 minutes). Associated findings include dyspnea, nausea, vomiting, tachycardia, dizziness, diaphoresis, belching, and palpitations. You may hear an atrial gallop (a fourth heart sound) or murmur during an anginal episode.

With Prinzmetal's angina, caused by vasospasm of coronary vessels, chest pain typically occurs when the patient is at rest—or it may awaken him. It may be accompanied by shortness of breath, nausea, vomiting, dizziness, and palpitations. During an attack, you may hear an atrial gallop.

Anthrax (inhalation).Inhalation anthrax is caused by inhalation of aerosolized spores. Initial signs and symptoms are flulike and include a fever, chills, weakness, a cough, and chest pain. The disease generally occurs in two stages with a period of recovery after the initial signs and symptoms. The second stage develops abruptly with rapid deterioration marked by a fever, dyspnea, stridor, and hypotension, generally leading to death within 24 hours. Radiologic findings include mediastinitis and symmetric mediastinal widening.

Anxiety.Acute anxiety—or, more commonly, panic attacks—can produce intermittent, sharp, stabbing pain, commonly located behind the left breast. This pain isn't related to exertion and lasts only a few seconds, but the patient may experience a precordial ache or a sensation of heaviness that lasts for hours or days. Associated signs and symptoms include precordial tenderness, palpitations, fatigue, a headache, insomnia, breathlessness, nausea, vomiting, diarrhea, and tremors. Panic attacks may be associated with agoraphobia—fear of leaving home or being in open places with other people.

Aortic aneurysm (dissecting).The chest pain associated with a dissecting aortic aneurysm usually begins suddenly and is most severe at its onset. The patient describes an excruciating tearing, ripping, stabbing pain in his chest and neck that radiates to his upper back, abdomen, and lower back. He may also have abdominal tenderness, a palpable abdominal mass, tachycardia, murmurs, syncope, blindness, loss of consciousness, weakness or transient paralysis of the arms or legs, a systolic bruit, systemic hypotension, asymmetrical brachial pulses, a lower blood pressure in the legs than in the arms, and weak or absent femoral or pedal pulses. His skin is pale, cool, diaphoretic, and mottled below the waist. Capillary refill time is increased in the toes, and palpation reveals decreased pulsation in one or both carotid arteries.

Asthma.In a life-threatening asthma attack, diffuse and painful chest tightness arises suddenly along with a dry cough and mild wheezing, which progress to a productive cough, audible wheezing, and severe dyspnea. Related respiratory findings include rhonchi, crackles, prolonged expirations, intercostal and supraclavicular retractions on inspiration, accessory muscle use, flaring nostrils, and tachypnea. The patient may also experience anxiety, tachycardia, diaphoresis, flushing, and cyanosis.

Blast lung injury.Caused by a percussive shock wave after an explosion, blast lung injury can cause severe chest pain and possibly tearing, contusion, edema, and hemorrhage of the lungs of affected people. Worldwide terrorist activity has recently increased the incidence of this condition, which may also cause dyspnea, hemoptysis, wheezing, and cyanosis. Chest X-rays, arterial blood gas measurements, and computed tomography scans are common diagnostic tools. Although no definitive guidelines exist for caring for those with blast lung injury, treatment is based on the nature of the explosion, the environment in which it occurred, and any chemical or biological agents involved.

Bronchitis.In its acute form, bronchitis produces a burning chest pain or a sensation of substernal tightness. It also produces a cough, initially dry but later productive, that worsens the chest pain. Other findings include a low-grade fever, chills, a sore throat, tachycardia, muscle and back pain, rhonchi, crackles, and wheezing. Severe bronchitis causes a fever of 101º to 102º F (38.3º to 38.9º C) and possible bronchospasm with worsening wheezing and increased coughing.

Cholecystitis.Cholecystitis typically produces abrupt epigastric or right upper quadrant pain, which may be sharp or intensely aching. Steady or intermittent pain may radiate to the back or right shoulder. Commonly associated findings include nausea, vomiting, a fever, diaphoresis, and chills. Palpation of the right upper quadrant may reveal an abdominal mass, rigidity, distention, or tenderness. Murphy's sign—inspiratory arrest elicited when the examiner palpates the right upper quadrant as the patient takes a deep breath—may also occur.

Interstitial lung disease.As interstitial lung disease advances, the patient may experience pleuritic chest pain along with progressive dyspnea, cellophane-type crackles, a nonproductive cough, fatigue, weight loss, decreased exercise tolerance, clubbing, and cyanosis.

Lung abscess.Pleuritic chest pain develops insidiously with a lung abscess along with a pleural friction rub and a cough that raises copious amounts of purulent, foul-smelling, blood-tinged sputum. The affected side is dull to percussion, and decreased breath sounds and crackles may be heard. The patient also displays diaphoresis, anorexia, weight loss, a fever, chills, fatigue, weakness, dyspnea, and clubbing.

Lung cancer.The chest pain associated with lung cancer is commonly described as an intermittent aching felt deep within the chest. If the tumor metastasizes to the ribs or vertebrae, the pain becomes localized, continuous, and gnawing. Associated findings include cough (sometimes bloody), wheezing, dyspnea, fatigue, anorexia, weight loss, and a fever.

Mitral valve prolapse.Most patients with mitral valve prolapse are asymptomatic, but some may experience sharp, stabbing precordial chest pain or precordial ache. The pain can last for seconds or for hours and occasionally mimics the pain of ischemic heart disease. The characteristic sign of mitral prolapse is a midsystolic click followed by a systolic murmur at the apex. Patients may experience cardiac awareness, a migraine headache, dizziness, weakness, episodic severe fatigue, dyspnea, tachycardia, mood swings, and palpitations.

Myocardial infarction (MI).The chest pain during an MI lasts from 15 minutes to hours. Typically a crushing substernal pain unrelieved by rest or nitroglycerin, it may radiate to the patient's left arm, jaw, neck, or shoulder blades. Women are less likely to experience chest pain with an MI, but may complain of pain in the shoulder blade, jaw, and upper back. Other findings include pallor, clammy skin, dyspnea, diaphoresis, nausea, vomiting, anxiety, restlessness, a feeling of impending doom, hypotension or hypertension, an atrial gallop, murmurs, and crackles. Women also complain of fatigue, palpitations, and indigestion.

Pancreatitis.In the acute form, pancreatitis usually causes intense pain in the epigastric area that radiates to the back and worsens when the patient is in a supine position. Nausea, vomiting, a fever, abdominal tenderness and rigidity, diminished bowel sounds, and crackles at the lung bases may also occur. A patient with severe pancreatitis may be extremely restless and have mottled skin, tachycardia, and cold, sweaty extremities. Fulminant pancreatitis causes massive hemorrhage, resulting in shock and coma.

Peptic ulcer.With a peptic ulcer, sharp and burning pain usually arises in the epigastric region. This pain characteristically arises hours after food intake, commonly during the night. It lasts longer than angina-like pain and is relieved by food or an antacid. Other findings include nausea, vomiting (sometimes with blood), melena, and epigastric tenderness.

Pericarditis.Pericarditis produces precordial or retrosternal pain aggravated by deep breathing, coughing, position changes, and occasionally by swallowing. The pain is commonly sharp or cutting and radiates to the shoulder and neck. Associated signs and symptoms include a pericardial friction rub, a fever, tachycardia, and dyspnea. Pericarditis usually follows a viral illness, but several other causes should be considered.

Plague(Yersinia pestis).Signs and symptoms of the plague include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of the flea bite. Septicemic plague develops as a fulminant illness generally with the bubonic form. The pneumonic form may be contracted from person-to-person through direct contact via the respiratory system or through biological warfare from aerosolization and inhalation of the organism. The onset is usually sudden with chills, a fever, a headache, and myalgia. Pulmonary signs and symptoms include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.

Pleurisy.The chest pain of pleurisy arises abruptly and reaches maximum intensity within a few hours. The pain is sharp, even knifelike, usually unilateral, and located in the lower and lateral aspects of the chest. Deep breathing, coughing, or thoracic movement characteristically aggravates it. Auscultation over the painful area may reveal decreased breath sounds, inspiratory crackles, and a pleural friction rub. Dyspnea; rapid, shallow breathing; cyanosis; a fever; and fatigue may also occur.

Pneumonia.Pneumonia produces pleuritic chest pain that increases with deep inspiration and is accompanied by shaking chills and fever. The patient has a dry cough that later becomes productive. Other signs and symptoms include crackles, rhonchi, tachycardia, tachypnea, myalgia, fatigue, a headache, dyspnea, abdominal pain, anorexia, cyanosis, decreased breath sounds, and diaphoresis.

Pneumothorax.Spontaneous pneumothorax, a life-threatening disorder, causes sudden sharp chest pain that's severe, typically unilateral, and rarely localized; it increases with chest movement. When the pain is centrally located and radiates to the neck, it may mimic that of an MI. After the pain's onset, dyspnea and cyanosis progressively worsen. Breath sounds are decreased or absent on the affected side with hyperresonance or tympany, subcutaneous crepitation, and decreased vocal fremitus. Asymmetrical chest expansion, accessory muscle use, a nonproductive cough, tachypnea, tachycardia, anxiety, and restlessness also occur.

Pulmonary embolism.A pulmonary embolism produces chest pain or a choking sensation. Typically, the patient first experiences sudden dyspnea with intense angina-like or pleuritic pain aggravated by deep breathing and thoracic movement. Other findings include tachycardia, tachypnea, decreased pulse oximetry, a cough (nonproductive or producing blood-tinged sputum), a low-grade fever, restlessness, diaphoresis, crackles, a pleural friction rub, diffuse wheezing, dullness to percussion, signs of circulatory collapse (a weak, rapid pulse; hypotension), paradoxical pulse, signs of cerebral ischemia (transient unconsciousness, coma, seizures), signs of hypoxia (restlessness) and, particularly in the elderly, hemiplegia and other focal neurologic deficits. Less common signs include massive hemoptysis, chest splinting, and leg edema. A patient with a large embolus may have cyanosis and jugular vein distention.

Q fever.Signs and symptoms of Q fever include a fever, chills, a severe headache, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last up to 2 weeks. In severe cases, the patient may develop hepatitis or pneumonia.

Sickle cell crisis.Chest pain associated with sickle cell crisis typically has a bizarre distribution. It may start as a vague pain, commonly located in the back, hands, or feet. As the pain worsens, it becomes generalized or localized to the abdomen or chest, causing severe pleuritic pain. The presence of chest pain and difficulty breathing requires prompt intervention. The patient may also have abdominal distention and rigidity, dyspnea, a fever, and jaundice.

Thoracic outlet syndrome.Commonly causing paresthesia along the ulnar distribution of the arm, thoracic outlet syndrome can be confused with angina, especially when it affects the left arm. The patient usually experiences angina-like pain after lifting his arms above his head, working with his hands above his shoulders, or lifting a weight. The pain disappears as soon as he lowers his arms. Other signs and symptoms include pale skin and a difference in blood pressure between both arms.

Tuberculosis (TB).In a patient with TB, pleuritic chest pain and fine crackles occur after coughing. Associated signs and symptoms include night sweats, anorexia, weight loss, a fever, malaise, dyspnea, easy fatigability, a mild to severe productive cough, occasional hemoptysis, dullness to percussion, increased tactile fremitus, and amphoric breath sounds.

Tularemia.Signs and symptoms of tularemia following inhalation of the organism include the abrupt onset of a fever, chills, a headache, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Chinese restaurant syndrome (CRS).CRS is a benign condition—a reaction to excessive ingestion of monosodium glutamate, a common additive in Chinese foods—that mimics the signs of an acute MI. The patient may complain of retrosternal burning, ache, or pressure; a burning sensation over his arms, legs, and face; a sensation of facial pressure; a headache; shortness of breath; and tachycardia.

Drugs.The abrupt withdrawal of a beta-adrenergic blocker can cause rebound angina if the patient has coronary heart disease—especially if he has received high doses for a prolonged period.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Chest Pain - Case 14-1: 17-Year-Old Boy: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

As mentioned previously, chest pain in children and adolescents is rarely life-threatening. The majority of cases of chest pain in these age groups are classified as idiopathic. Among adolescents, the most common nonidiopathic causes are psychogenic origin, cough, asthma, pneumonia, and musculoskeletal pain. Less common causes include trauma, drug use or abuse, gastroesophageal reflux, and pneumothorax. Cardiac causes are exceedingly uncommon but should be considered in certain clinical situations, such as a patient with syncope and exertional or positional symptoms.
This patient had many physical and laboratory findings that warranted further evaluation. The two most worrisome findings were his chest pain when supine and his DVT. Shortness of breath and chest pain that worsen with supine lying suggest possible pericardial disease. The development of DVT in an otherwise healthy adolescent is extremely uncommon. In this situation, one should suspect underlying hypercoagulation disorders. Finally, this DVT in conjunction with shortness of breath and chest pain suggested pulmonary embolus as a possible diagnosis.

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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Chest Pain - Case 14-2: 15-Year-Old Boy: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

Chest pain in an adolescent boy is rarely life-threatening. However, a careful history and physical examination must be undertaken to determine which cases require further investigations.
The majority of cases of chest pain in childhood are classified as idiopathic. Adolescents are more likely to have psychogenic causes for their chest pain than younger children, with this diagnosis being more common in girls. Musculoskeletal causes are quite common, including muscle strain, trauma, and costochondritis. Other common causes are cough, asthma, and pneumonia. Less commonly, chest pain in adolescents is caused by gastroesophageal reflux, pneumothorax, pneumomediastinum, or pleural effusion. In an adolescent with chest pain, it is important to inquire about tobacco, cocaine, and methamphetamine use, all of which can be associated with chest pain. In adolescent girls, one should consider pubertal breast development or fibrocystic breast disease, and in boys, gynecomastia. Rarely, but importantly, one should consider cardiovascular causes of chest pain, including structural diseases (e.g., idiopathic hypertrophic cardiomyopathy), coronary artery disease, myocarditis, pericarditis, and arrhythmias.
The features of this case that warrant further evaluation include the acute onset of the chest pain and the variability with positional changes.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Chest Pain - Case 14-3: 20-Year-Old Boy: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

As previously mentioned, the most common causes for chest pain in the adolescent age group are asthma, pneumonia, cough, musculoskeletal causes, psychogenic pain, and idiopathic causes.
The concerning factors in this patient were his positional shortness of breath, his family history of early myocardial infarction, and his abnormal ECG findings. On presentation, he was tachycardic and febrile. The acute nature of his symptoms and the positional nature of his respiratory symptoms should raise the concern for a possible cardiac etiology. Although cardiac causes are rare among all causes of chest pain, they can be the most life-threatening and must be evaluated.
Cardiac causes for chest pain include structural lesions such as aortic or pulmonic stenosis, idiopathic hypertrophic subaortic stenosis (IHSS), and mitral valve prolapse. Patients with IHSS often have a family history of sudden death. Coronary artery disease can also lead to chest pain and may be secondary to anomalous coronary arteries, Kawasaki disease, or long-standing diabetes mellitus. Patients with either corrected or uncorrected congenital heart disease may complain of chest pain, which must be carefully evaluated. Arrhythmias such as supraventricular tachycardia and ventricular tachycardia can also manifest with chest pain and palpitations. Finally, infectious causes such as myocarditis and pericarditis may manifest with chest pain.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Chest Pain - Case 14-4: 17-Year-Old Boy: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

The differential diagnosis for chest pain in this adolescent boy focused on the acute nature of his pain. In general, the most common causes for chest pain in the adolescent age group are psychogenic pain, cough, asthma, musculoskeletal pain, and pneumonia. These causes most often produce a subacute and subtle type of chest pain.
Therefore, the acute onset of chest pain in this boy should focus the differential diagnosis on a number of other causes. Certainly, tobacco use or the abuse of cocaine or methamphetamine could cause the acute onset of chest pain secondary to vasospasm of the coronary arteries. Pneumothorax or pneumomediastinum commonly manifest with the acute onset of chest pain. Some abdominal processes, such as pancreatitis or cholecystitis, may manifest with acute chest pain. Cardiovascular causes are less common but are life-threatening. With acute chest pain, one should consider coronary artery disease, arrhythmias, structural cardiac defects, and infections.

» READ BOOK EXCERPT ONLINE »

Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Chest Pain - Case 14-5: 3-Year-Old Girl: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

As with adolescents, chest pain in the school age child is very rarely a life-threatening condition. Common causes of chest pain in this age group include cough, asthma, pneumonia, and musculoskeletal causes (muscle strain, trauma, costochondritis.) It is quite common as well for chest pain to be deemed idiopathic. Less commonly, a child with gastroesophageal reflux, pneumothorax or pneumomediastinum, and pleural effusion presents with chest pain. As in older children, the history and physical examination are crucial in guiding the appropriate workup.
Rarely, one sees a child with chest pain and cardiovascular disease. However, because this is the diagnosis that most families are concerned about, it must be addressed. Certainly, children with palpitations, syncope, or chest pain with exertion should have a thorough evaluation. Finally, toddlers are always at risk for foreign body ingestion. Although aspirated foreign bodies are not likely to give chest pain, esophageal foreign bodies commonly cause chest pain.

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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Chest Pain - Case 14-6: 15-Year-Old Boy: I. Differential Diagnosis
(Pediatric Complaints and Diagnostic Dilemmas)

The most common causes for chest pain in the adolescent age group are cough, asthma, pneumonia, musculoskeletal causes, and idiopathic causes. With this patient 's past medical history of asthma, it was natural for asthma to be the initial focus of concern. However, because the patient 's physical examination was not consistent with an asthma exacerbation, other diagnoses were appropriately considered. The concerning features on this patient 's physical examination included signs of congestive heart failure: bilateral rales, a gallop, and a palpable liver edge 3 cm below the right costal margin. Furthermore, his shortness of breath was significantly worse while lying down. Dyspnea with an asthma exacerbation is not usually positional in nature to this extent.
The differential diagnosis for heart failure in this adolescent includes congenital heart disease —both pressure overload (e.g., aortic stenosis) and volume overload (e.g., aortic regurgitation, arrhythmias); acquired heart disease (myocarditis, cardiomyopathy, pericarditis, cor pulmonale, endocarditis); hypoglycemia; storage diseases; and ingestions such as cardiac toxins (e.g., digitalis) and arrhythmogenics (e.g., tricyclic antidepressants).

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Source: Pediatric Complaints and Diagnostic Dilemmas, 2003

Chest Pain: Chest Pain - etiology
(The 5-Minute Pediatric Consult)

Most common causes of pediatric chest pain

  • Idiopathic
  • Musculoskeletal:
    • Chest wall strain
    • Costochondritis
    • Direct trauma
  • Respiratory conditions:
    • Asthma, cough, pneumonia
  • Gastrointestinal problems:
    • Esophagitis, esophageal foreign body
    • Psychogenic—stress related
  • Cardiac pathology
 

» READ BOOK EXCERPT ONLINE »

Source: The 5-Minute Pediatric Consult, 2008


 » Next page: Risk Factors for Chest pain

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