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Causes of Panic attack
List of causes of Panic attack
Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Panic attack) that could possibly cause Panic attack includes:
- Panic disorder
- Panic disorder with agoraphobia (type of Panic disorder)
- Panic disorder without agoraphobia (type of Panic disorder)
- Substance-induced anxiety disorder (type of Anxiety Disorders)
- Anxiety disorders - certain other types of anxiety disorders can lead to panic attacks:
- Social phobia
- Specific phobia (type of Phobias)
- Obsessive-compulsive disorder
- Post-traumatic stress disorder
- Separation anxiety disorder
- Adjustment disorder
- Substance-induced anxiety disorder (type of Anxiety Disorders)
- See also causes of symptoms panic or anxiety
More causes: see full list of causes for Panic attack
Causes of Panic attack: Online Medical Books
16 MEDICAL BOOKS ONLINE! Review the full text of medical books online, free, without registration, for more information about the causes of Panic attack.
Anxiety:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Generalized anxiety disorder
–Excessive worry associated with at least three symptoms, including restlessness or edgy feeling, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbance
–The most common anxiety disorder in primary care - Panic disorder
–Recurrent, unpredictable panic attacks with intense apprehension, fear or terror, and somatic symptoms (e.g., tachycardia)
–May present with or without agoraphobia - Depression: Anxiety often presents in a mixed state with depression
- Medications (e.g., bronchodilators, steroids, antidepressants, antihypertensives)
- Substance use, including drugs (e.g., alcohol, caffeine, cocaine, cannabis)
-
Obsessive-compulsive disorder
–Obsessions are persistent ideas, images, or impulses that generate anxiety
–Compulsions are intentional repetitive behaviors or mental acts aimed at reducing the distress of obsessions- Anxiety disorder due to a general medical condition
–Cardiovascular etiologies include MI, angina, arrhythmias, CAD, CHF, MVP
–Respiratory etiologies include asthma, COPD, and pulmonary embolism
–Endocrine etiologies include hyper- or hypothyroidism, hypoglycemia, and Cushing's syndrome
–Neurological etiologies include Parkinson's disease and epilepsy
–Cancer - Pheochromocytoma: Adrenal tumor that usually presents with hypertension and increased heart rate and sometimes with fright reaction of sweating, headache, and pale facial appearance
- Parkinson's disease: Presents with tremor at rest, usually in one hand (as opposed to the more generalized essential tremor in anxiety)
- Post-traumatic or acute stress disorder
- Social anxiety disorder
- Specific phobia
- Bipolar disorder (especially manic stage)
- Anxiety disorder due to a general medical condition
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
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
Agitation:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
❑ Alcohol withdrawal syndrome. Mild to severe agitation occurs in alcohol withdrawal syndrome, along with hyperactivity, tremors, and anxiety. With delirium, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and a depressed mood. The patient’s pulse rate and temperature rise as withdrawal progresses; status epilepticus, cardiac exhaustion, and shock can occur.
❑ Anxiety. Anxiety produces varying degrees of agitation. The patient may be unaware of his anxiety or may complain of it without knowing its cause. Other findings include nausea, vomiting, diarrhea, cool and clammy skin, frontal headache, back pain, insomnia, and tremors.
❑ Dementia. Mild to severe agitation can result from many common syndromes, such as Alzheimer’s and Huntington’s diseases. The patient may display a decrease in memory, attention span, problem-solving ability, and alertness. Hypoactivity, wandering behavior, hallucinations, aphasia, and insomnia may also occur.
❑ Drug withdrawal syndrome. Mild to severe agitation occurs in drug withdrawal syndrome. Related findings vary with the drug, but include anxiety, abdominal cramps, diaphoresis, and anorexia. With opioid or barbiturate withdrawal, a decreased level of consciousness (LOC), seizures, and elevated blood pressure, heart rate, and respiratory rate can also occur.
❑ Hepatic encephalopathy. Agitation occurs only with fulminating encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus, asterixis, and hyperreflexia.
❑ Hypersensitivity reaction. Moderate to severe agitation appears, possibly as the first sign of a reaction. Depending on the severity of the reaction, agitation may be accompanied by urticaria, pruritus, and facial and dependent edema.
With anaphylactic shock, a potentially life-threatening reaction, agitation occurs rapidly along with apprehension, urticaria or diffuse erythema, warm and moist skin, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.
❑ Hypoxemia. Beginning as restlessness, agitation rapidly worsens. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.
❑ Increased intracranial pressure (ICP). Agitation usually precedes other early signs and symptoms, such as head-ache, nausea, and vomiting. Increased ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; a decreased LOC; seizures; and motor changes such as decerebrate or decorticate posture.
❑ Post-head trauma syndrome. Shortly after, or even years after injury, mild to severe agitation develops, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Other findings include fatigue, wandering behavior, and poor judgment.
❑ Vitamin B6 deficiency. Agitation can range from mild to severe. Other effects include seizures, peripheral paresthesia, and dermatitis. Oculogyric crisis may also occur.
Other causes
❑ Drugs. Mild to moderate agitation, which is commonly dose related, develops as an adverse reaction to central nervous system stimulants — especially appetite suppressants, such as amphetamines and amphetamine-like drugs; sympathomimetics, such as ephedrine; caffeine; and theophylline.
❑ Radiographic contrast media. Reaction to the contrast medium injected during various diagnostic tests produces moderate to severe agitation along with other signs of hypersensitivity.
Anxiety:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
❑ Acute respiratory distress syndrome. Acute anxiety occurs along with tachycardia, mental sluggishness and, in severe cases, hypotension. Other respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, and rhonchi.
❑ Anaphylactic shock. Acute anxiety usually signals the onset of anaphylactic shock. It’s accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, a barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.
❑ Angina pectoris. Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.
❑ Asthma. With allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, a productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.
❑ Autonomic hyperreflexia. The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.
❑ Cardiogenic shock. Acute anxiety is accompanied by cool, pale, clammy skin; tachycardia; a weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.
❑ Chronic obstructive pulmonary disease (COPD). Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize COPD.
❑ Heart failure. With heart failure, acute anxiety is commonly the first symptom of inadequate oxygenation. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, and cyanosis.
❑ Hyperthyroidism. Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, sweating, an enlarged thyroid, and diarrhea. Exophthalmos may occur.
❑ Mitral valve prolapse. Panic may occur in patients with mitral valve prolapse, referred to as the click-murmur syndrome. The disorder may also cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. Its hallmark is a midsystolic click, followed by an apical systolic murmur.
❑ Mood disorder. Anxiety may be the patient’s chief complaint in the depressive or manic form of mood disorder. With the depressive form, chronic anxiety occurs with varying severity. Associated findings include dysphoria; anger; insomnia or hypersomnia; decreased libido, interest, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts. With the manic form, the patient’s chief complaint may be a reduced need for sleep, hyperactivity, increased energy, rapid or pressured speech and, in severe cases, paranoid ideas and other psychotic symptoms.
❑ Myocardial infarction (MI). With MI, a life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. It can be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.
❑ Obsessive-compulsive disorder. Chronic anxiety occurs with obsessive-compulsive disorder, along with recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational, but is unable to control them. Anxiety builds if he can’t perform these acts and diminishes after he does.
❑ Pheochromocytoma. Acute, severe anxiety accompanies pheochromocytoma’s cardinal sign: persistent or paroxysmal hypertension. Common associated signs and symptoms include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, a severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.
❑ Phobias. With phobias, chronic anxiety occurs along with a persistent fear of an object, activity, or situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational, but can’t suppress it.
❑ Pneumonia. Acute anxiety may occur with pneumonia because of hypoxemia. Other findings include a productive cough, pleuritic chest pain, fever, chills, crackles, diminished breath sounds, and hyperresonant lung fields.
❑ Pneumothorax. Acute anxiety occurs in moderate to severe pneumothorax associated with profound respiratory distress. It’s accompanied by sharp pleuritic pain, coughing, shortness of breath, cyanosis, asymmetrical chest expansion, pallor, jugular vein distention, and a weak, rapid pulse.
❑ Postconcussion syndrome. Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. Associated signs and symptoms include irritability, insomnia, dizziness, and a mild headache. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension.
❑ Posttraumatic stress disorder. Posttraumatic stress disorder occurs in the patient who has experienced an extreme traumatic event. It produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.
❑ Pulmonary edema. With pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, ventricular gallop, hypotension, and a thready pulse. The patient’s skin may be cool, clammy, and cyanotic.
❑ Pulmonary embolism. With pulmonary embolism, acute anxiety is usually accompanied by dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and a low-grade fever.
❑ Rabies. Anxiety signals the beginning of the acute phase of rabies, a rare disorder, which is commonly accompanied by painful laryngeal spasms associated with difficulty swallowing and, as a result, hydrophobia.
❑ Somatoform disorder. Somatoform disorder, which usually begins in young adulthood, is characterized by anxiety and multiple somatic complaints that can’t be explained physiologically. The symptoms aren’t produced intentionally, but are severe enough to significantly impair functioning. Pain disorder, conversion disorder, and hypochondriasis are examples of somatoform disorder.
Other causes
❑ Drugs. Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.
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.
Skin, clammy:
Medical causes
(Handbook of Signs & Symptoms (Third Edition))
Anxiety
An acute anxiety attack commonly produces cold, clammy skin on the forehead, palms, and soles. Other features include pallor, a dry mouth, tachycardia or bradycardia, palpitations, and hypertension or hypotension. The patient may also develop tremors, breathlessness, a headache, muscle tension, nausea, vomiting, abdominal distention, diarrhea, increased urination, and sharp chest pain.
Arrhythmias
Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension.
Cardiogenic shock
Generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria.
Heat exhaustion
In the acute stage of heat exhaustion, generalized cold, clammy skin accompanies an ashen appearance, a headache, confusion, syncope, giddiness and, possibly, a subnormal temperature, with mild heat exhaustion. The patient may exhibit a rapid and thready pulse, nausea, vomiting, tachypnea, oliguria, thirst, muscle cramps, and hypotension.
Hypoglycemia (acute)
Generalized cool, clammy skin or diaphoresis may accompany irritability, tremors, palpitations, hunger, a headache, tachycardia, and anxiety. Central nervous system disturbances include blurred vision, diplopia, confusion, motor weakness, hemiplegia, and coma. These signs and symptoms typically resolve after the patient is given glucose.
Hypovolemic shock
With hypovolemic shock, generalized pale, cold, clammy skin accompanies a subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and a rapid, thready pulse. Other findings are flat neck veins, an increased capillary refill time, decreased urine output, confusion, and a decreased level of consciousness.
Septic shock
The cold shock stage causes generalized cold, clammy skin. Associated findings include a rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.
Generalized anxiety disorder:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
Theorists share a common premise: Conflict, whether intrapsychic, sociopersonal, or interpersonal, promotes an anxiety state.
Generalized anxiety disorder has a 1-year prevalence range from 3% to 8%. It’s more common in women than in men, and half of all cases begin in childhood or adolescence.
Panic disorder:
Causes and incidence
(Professional Guide to Diseases (Eighth Edition))
Like other anxiety disorders, panic disorder may stem from a combination of physical and psychological factors. For example, some theorists emphasize the role of stressful events or unconscious conflicts that occur early in childhood.
Recent evidence indicates that alterations in brain biochemistry, especially in norepinephrine, serotonin, and gamma-aminobutyric acid activity, may also contribute to panic disorder.
Panic disorder affects about 2% of the population. Symptoms usually develop before age 25.
Agitation:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Affective disturbances
Agitation may occur in either the depressive or manic phase of affective disturbances and in personality disorders, such as borderline and antisocial personality disorders. The hallmark of the depressive form is depressed mood upon awakening, which eases during the day. Chronic anxiety may be mild or severe. Psychomotor agitation may be characterized by an inability to sit still, hand-wringing, pacing, and irritability. Other findings in the manic state may include decreased sleep, pressured speech, and grandiosity.
Alcohol withdrawal syndrome
Mild to severe agitation occurs with hyperactivity, tremors, and anxiety. In delirium tremens, the potentially life-threatening stage of alcohol withdrawal, severe agitation accompanies hallucinations, insomnia, diaphoresis, and depressed mood. Pulse rate and temperature rise as withdrawal progresses; status epilepticus, cardiac arrhythmias, and shock can occur.
Anxiety
Anxiety is a common symptom that produces varying degrees of agitation. The patient may be unaware of his anxiety or may complain of it without knowing its cause. Other findings may include nausea, vomiting, diarrhea, cool and clammy skin, frontal headache, back pain, insomnia, and tremors.
Chronic renal failure
Moderate to severe agitation occurs in chronic renal failure, which is marked by confusion and memory loss. The agitation is accompanied by diverse signs and symptoms, such as nausea, vomiting, anorexia, mouth ulcers, ammonia breath odor, GI bleeding, pallor, edema, dry skin, and uremic frost.
Dementia
Mild to severe agitation can result from many common dementia syndromes, such as Alzheimer’s and Huntington’s diseases. The patient may display a decrease in memory, attention span, problem-solving ability, and alertness. Hypoactivity, wandering behavior, hallucinations, aphasia, and insomnia may also occur.
Drug withdrawal syndrome
Findings vary with the drug but include mild to severe agitation, anxiety, abdominal cramps, diaphoresis, and anorexia. In opioid or barbiturate withdrawal, a decreased level of consciousness (LOC), seizures, and elevated blood pressure, heart rate, and respiratory rate can also occur.
Hepatic encephalopathy
Agitation occurs only in fulminating encephalopathy. Other findings include drowsiness, stupor, fetor hepaticus, asterixis, and hyperreflexia.
Hypersensitivity reaction
Moderate to severe agitation may be the first sign of a hypersensitivity reaction. Depending on the severity of the reaction, agitation may be accompanied by urticaria, pruritus, and facial and dependent edema.
In anaphylactic shock, a potentially life-threatening reaction, agitation occurs rapidly along with apprehension, urticaria or diffuse erythema, warm and moist skin, paresthesia, pruritus, edema, dyspnea, wheezing, stridor, hypotension, and tachycardia. Abdominal cramps, vomiting, and diarrhea can also occur.
Hypoxemia
Beginning as restlessness, agitation rapidly worsens in hypoxemia. The patient may be confused and have impaired judgment and motor coordination. He may also have tachycardia, tachypnea, dyspnea, and cyanosis.
Increased intracranial pressure (ICP)
Agitation usually precedes other early signs and symptoms, such as headache, nausea, and vomiting. Increased ICP produces respiratory changes, such as Cheyne-Stokes, cluster, ataxic, or apneustic breathing; sluggish, nonreactive, or unequal pupils; widening pulse pressure; tachycardia; decreased LOC; seizures; and motor changes, such as decerebrate or decorticate posture.
Organic brain syndrome
In organic brain syndrome, agitation is manifested as hyperactivity, emotional lability, confusion, and memory loss. Slurred or incoherent speech and paranoid behavior may also occur.
Post–head trauma syndrome
Shortly—or even years—after injury, mild to severe agitation develops, characterized by disorientation, loss of concentration, angry outbursts, and emotional lability. Fatigue, wandering behavior, and poor judgment are other findings.
Vitamin B6 Deficiency
Agitation can range from mild to severe. Other effects include seizures, peripheral paresthesia, and dermatitis. Oculogyric crisis may also occur.
Other causes
Drugs
Mild to moderate agitation, which is commonly dose related, is an adverse effect of central nervous system stimulants—especially appetite suppressants, such as amphetamines and amphetamine-like drugs; sympathomimetics such as ephedrine; caffeine; and theophylline.
Radiographic contrast media
Injection of a contrast medium during various diagnostic tests may produce moderate to severe agitation along with other signs of hypersensitivity.
Anxiety:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Acute respiratory distress syndrome
Acute anxiety occurs along with tachycardia, mental sluggishness and, in severe cases, hypotension. Respiratory signs and symptoms include dyspnea, tachypnea, intercostal and suprasternal retractions, crackles, and rhonchi.
Anaphylactic shock
Acute anxiety is usually the first sign of anaphylactic shock. It’s accompanied by urticaria, angioedema, pruritus, and shortness of breath. Soon, other signs and symptoms develop: light-headedness, hypotension, tachycardia, nasal congestion, sneezing, wheezing, dyspnea, barking cough, abdominal cramps, vomiting, diarrhea, and urinary urgency and incontinence.
Angina pectoris
Acute anxiety may either precede or follow an attack of angina pectoris. An attack produces sharp and crushing substernal or anterior chest pain that may radiate to the back, neck, arms, or jaw. The pain may be relieved by nitroglycerin or rest, which eases anxiety.
Asthma
In allergic asthma attacks, acute anxiety occurs with dyspnea, wheezing, productive cough, accessory muscle use, hyperresonant lung fields, diminished breath sounds, coarse crackles, cyanosis, tachycardia, and diaphoresis.
Autonomic hyperreflexia
The earliest signs of autonomic hyperreflexia may be acute anxiety accompanied by a severe headache and dramatic hypertension. Pallor and motor and sensory deficits occur below the level of the lesion; flushing occurs above it.
Cardiogenic shock
Acute anxiety is accompanied by cool, pale, clammy skin; tachycardia; weak, thready pulse; tachypnea; ventricular gallop; crackles; jugular vein distention; decreased urine output; hypotension; narrowing pulse pressure; and peripheral edema.
Chronic obstructive pulmonary disease (COPD)
Acute anxiety, exertional dyspnea, cough, wheezing, crackles, hyperresonant lung fields, tachypnea, and accessory muscle use characterize COPD.
Heart failure
In heart failure, acute anxiety is commonly the first symptom of inadequate oxygenation. Associated findings include restlessness, shortness of breath, tachypnea, decreased LOC, edema, crackles, ventricular gallop, hypotension, diaphoresis, and cyanosis.
Hyperthyroidism
Acute anxiety may be an early sign of hyperthyroidism. Classic signs and symptoms include heat intolerance, weight loss despite increased appetite, nervousness, tremor, palpitations, diaphoresis, an enlarged thyroid, and diarrhea. Exophthalmos also may occur.
Hyperventilation syndrome
Hyperventilation syndrome produces acute anxiety, pallor, circumoral and peripheral paresthesia and, occasionally, carpopedal spasms.
Hypochondriasis
Mild to moderate chronic anxiety occurs in hypochondriasis. The patient focuses more on the belief that he has a specific serious disease rather than on the actual symptoms. Difficulty swallowing, back pain, light-headedness, and upset stomach are common complaints. The patient tends to “physician hop” and isn’t reassured by favorable physical examinations and laboratory test results.
Hypoglycemia
Anxiety resulting from hypoglycemia is usually mild to moderate and associated with hunger, mild headache, palpitations, blurred vision, weakness, and diaphoresis.
Mitral valve prolapse
Panic may occur in patients with this valvular disorder, also known as click-murmur syndrome because its hallmark is a midsystolic click, followed by an apical systolic murmur. Mitral valve prolapse also may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain.
Mood disorder
Anxiety may be the patient’s chief complaint in the depressive or manic form of mood disorder. In the depressive form, chronic anxiety of varying severity occurs along with dysphoria; anger; insomnia or hypersomnia; decreased libido, interest, energy, and concentration; appetite disturbance; multiple somatic complaints; and suicidal thoughts. In the manic form, the patient’s chief complaint may be a reduced need for sleep, hyperactivity, increased energy, rapid or pressured speech and, in severe cases, paranoid ideas and other psychotic symptoms.
Myocardial infarction (MI)
In this life-threatening disorder, acute anxiety commonly occurs with persistent, crushing substernal pain that may radiate to the left arm, jaw, neck, or shoulder blades. MI may be accompanied by shortness of breath, nausea, vomiting, diaphoresis, and cool, pale skin.
Obsessive-compulsive disorder
Chronic anxiety occurs in obsessive-compulsive disorder, which is marked by recurrent, unshakable thoughts or impulses to perform ritualistic acts. The patient recognizes these acts as irrational but is unable to control them. Anxiety builds if he can’t perform these acts and diminishes after he does.
Pheochromocytoma
Acute, severe anxiety accompanies pheochromocytoma’s cardinal sign: persistent or paroxysmal hypertension. Other common findings include tachycardia, diaphoresis, orthostatic hypotension, tachypnea, flushing, severe headache, palpitations, nausea, vomiting, epigastric pain, and paresthesia.
Phobias
In phobias, chronic anxiety accompanies persistent fear of an object, an activity, or a situation that results in a compelling desire to avoid it. The patient recognizes the fear as irrational but can’t suppress it.
Pneumonia
Acute anxiety may occur in pneumonia because of hypoxemia. Other findings include productive cough, pleuritic chest pain, fever, chills, crackles, diminished breath sounds, and hyperresonant lung fields.
Pneumothorax
Acute anxiety occurs in moderate to severe pneumothorax associated with profound respiratory distress. It’s accompanied by sharp pleuritic pain, coughing, shortness of breath, cyanosis, asymmetrical chest expansion, pallor, jugular vein distention, and a weak, rapid pulse.
Postconcussion syndrome
Postconcussion syndrome may produce chronic anxiety or periodic attacks of acute anxiety. The anxiety is usually most pronounced in situations demanding attention, judgment, or comprehension. Associated signs and symptoms include irritability, insomnia, dizziness, and mild headache.
Posttraumatic stress disorder
Posttraumatic stress disorder occurs in patients who have experienced an extremely traumatic event. It produces chronic anxiety of varying severity and is accompanied by intrusive, vivid memories and thoughts of the traumatic event. The patient also relives the event in dreams and nightmares. Insomnia, depression, and feelings of numbness and detachment are common.
Pulmonary edema
In pulmonary edema, acute anxiety occurs with dyspnea, orthopnea, cough with frothy sputum, tachycardia, tachypnea, crackles, ventricular gallop, hypotension, and thready pulse. The patient’s skin may be cool, clammy, and cyanotic.
Pulmonary embolism
Acute anxiety is usually accompanied by dyspnea, tachypnea, chest pain, tachycardia, blood-tinged sputum, and low-grade fever.
Rabies
Anxiety signals the beginning of the acute phase of rabies. This rare disorder is characterized by painful laryngeal spasms associated with difficulty swallowing and, as a result, hydrophobia.
Somatoform disorder
Somatoform disorder, which usually begins in young adulthood, is characterized by anxiety and multiple somatic complaints that can’t be explained physiologically. The symptoms aren’t produced intentionally but are severe enough to significantly impair functioning. Pain disorder, conversion disorder, and hypochondriasis are examples of somatoform disorder.
Other causes
Drugs
Many drugs cause anxiety, especially sympathomimetics and central nervous system stimulants. In addition, many antidepressants may cause paradoxical anxiety.
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.
Skin, clammy:
Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))
Anxiety
An acute anxiety attack commonly produces cold, clammy skin on the forehead, palms, and soles. Other features include pallor, dry mouth, tachycardia or bradycardia, palpitations, and hypertension or hypotension. The patient may also develop tremors, breathlessness, headache, muscle tension, nausea, vomiting, abdominal distention, diarrhea, increased urination, and sharp chest pain.
Arrhythmias
Cardiac arrhythmias may produce generalized cool, clammy skin along with mental status changes, dizziness, and hypotension.
Cardiogenic shock
Generalized cool, moist, pale skin accompanies confusion, restlessness, hypotension, tachycardia, tachypnea, narrowing pulse pressure, cyanosis, and oliguria.
Heat exhaustion
In the acute stage of heat exhaustion, generalized cold, clammy skin accompanies an ashen appearance, headache, confusion, syncope, giddiness and, possibly, a subnormal temperature, with mild heat exhaustion. The patient may exhibit a rapid and thready pulse, nausea, vomiting, tachypnea, oliguria, thirst, muscle cramps, and hypotension.
Hypoglycemia (acute)
Generalized cool, clammy skin or diaphoresis may accompany irritability, tremors, palpitations, hunger, headache, tachycardia, and anxiety. Central nervous system disturbances include blurred vision, diplopia, confusion, motor weakness, hemiplegia, and coma. These signs and symptoms typically resolve after the patient is given glucose.
Hypovolemic shock
With this common form of shock, generalized pale, cold, clammy skin accompanies subnormal body temperature, hypotension with narrowing pulse pressure, tachycardia, tachypnea, and rapid, thready pulse. Other findings are flat neck veins, increased capillary refill time, decreased urine output, confusion, and decreased level of consciousness.
Septic shock
The cold shock stage causes generalized cold, clammy skin. Associated findings include rapid and thready pulse, severe hypotension, persistent oliguria or anuria, and respiratory failure.
Anxiety:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Situational/characterologic
❑ Post-traumatic stress disorder
❑ Drugs/withdrawal
❑ Generalized anxiety disorder
❑ Panic disorder
❑ Phobia
❑ Agitated depression
❑ Hypoglycemia
❑ Hyperthyroidism
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
Pleuritic Chest Pain:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Costochondritis
❑ Pneumonia
❑ Rib fracture
❑ Pulmonary embolism
❑ Pleurisy
❑ Pneumothorax
❑ Pericarditis
❑ Lung cancer
❑ Pneumomediastinum
❑ Splenic infarction
Anxiety disorder, generalized:
Causes
(Handbook of Diseases)
Etiology is thought to involve the y-aminobutyric acid (GABA) A receptor–chloride ion channel complex. Benzodiazepines bind two separate GABA-A receptor sites: Type I has broad anatomic distribution, and type II is concentrated in the hippocampus, striatum, and neocortex. Serotonin (5-hydroxytryptamine [5-HT]) also appears to have a role in anxiety. Theorists share a common premise: Con-flict — whether intrapsychic, sociopersonal, or interpersonal — promotes an anxiety state.
Panic disorder:
Causes
(Handbook of Diseases)
As with other anxiety disorders, panic disorder may stem from a combination of physiologic and psychological factors. Evidence implicates hereditary and temporal lobe dysfunction, and some theorists emphasize the role of stressful events or unconscious conflicts that occur early in childhood. The disorder may also develop as a persistent pattern of maladaptive behavior acquired by learning.
Alterations in brain biochemistry, especially in norepinephrine, serotonin, and gamma-aminobutyric acid activity, may also contribute to panic disorder.
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.