CHEST PAIN

CHEST PAIN: Excerpt from Differential Diagnosis in Primary Care

Hardly a day goes by in a busy practitioner’s office that he or she is not confronted with a patient complaining of chest pain. The main concern, of course, is to exclude an acute myocardial infarction, which is not an easy task in many cases. The practitioner frequently admits the patient for observation, which is the safe thing to do when there is any doubt. With a list of virtually all the diagnostic possibilities in mind, however, fewer patients will require admission for observation. Anatomy forms the basis for formulating such a list.

CHEST PAIN

Visualizing the organs of the chest and cross-indexing them with the various etiologies (Table 14), one finds that at least 30 or 40 conditions must be considered.

Proceeding from the superficial to the deep structures, one encounters the skin, considers herpes zoster, and looks for a rash. Next, there is muscle; trichinosis, dermatomyositis, and contusion of the muscle must be considered. Cough-induced contusions should not be forgotten. In the same layer, the ribs and cartilage remind one of rib fractures, Tietze syndrome, metastatic carcinoma, and multiple myeloma. Other rarer conditions of the rib are shown in Table 14.

Many causes of chest pain arise from the pleura. Pneumonia with pleurisy, empyema, pulmonary infarction, and neoplasms of the pleura must be considered. Tuberculous pleurisy and other infectious agents are not uncommon. On the other hand, conditions of the lung are less likely to cause chest pain unless they involve the pleura: This is certainly true of pneumonia and neoplasms. A pneumothorax, however, is a very common cause of chest pain, especially in young adults.

Visualize the heart and the pericardium comes to mind. This is a source of chest pain in acute idiopathic pericarditis, rheumatic carditis, and tuberculous and neoplastic pericarditis. The myocardium is the source of the most serious form of chest pain, myocardial infarction, but here again the pain is more severe if the pericardium is involved. Angina pectoris and chronic coronary insufficiency are common causes of chest pain arising from the myocardium. Myocarditis (e.g., viral) causes less severe pain, but inflammation of the myocardium from postinfarction syndrome or postpericardiotomy syndrome can be extremely painful.

Now visualize the other central structures: The esophagus reminds one of reflux esophagitis and hiatal hernia, the mediastinum suggests mediastinitis and substernal thyroiditis or Hodgkin disease (usually not too painful), the aorta suggests dissecting aneurysms, and the thoracic spine suggests spinal cord tumors, osteoarthritis, Pott disease, fractures, herniated discs, as well as the other conditions listed in Table 14.

This chapter would not be complete unless referred pain to the chest was considered. Thus, abdominal conditions such as cholecystitis, pancreatitis, and splenic flexure syndrome may present with chest pain. Conditions of the neck that press the cervical nerves may also cause chest pain, particularly scalenus anticus syndrome, cervical ribs, and herniated discs of the cervical spine:

Neurocirculatory asthenia is associated with atypical chest pain; a psychiatric evaluation will assist in this diagnosis.

Approach to the Diagnosis

A possible myocardial infarction must be the first consideration in all adults with acute chest pain especially if there are significant alterations of the vital signs. Consequently, serial ECGs, serial cardiac enzymes, and hospitalization will often be necessary. Once this condition has been excluded, we can turn our attention to the other possibilities. Arterial blood gases, chest x-ray, and a lung scan may be ordered to exclude a pulmonary embolism. Pulmonary angiography may be necessary in some cases. A chest x-ray may be ordered to rule out pneumonia. Acute chest pain related to esophagitis is often relieved by swallowing lidocaine viscus, an extremely useful tool in the differential diagnosis. Relief of the pain with nitroglycerin under the tongue or by spray will support the diagnosis of coronary insufficiency. Tenderness of the costochondral junctions with relief on lidocaine injection into the point of maximum tenderness suggests Tietze syndrome (costochondritis). In cases of chronic chest pain, an exercise tolerance test with thallium scan should be done to rule out coronary insufficiency or myocardial infarct. It may be wise to do immediate coronary angiography if the condition deteriorates so that balloon angiography, bypass surgery, or reperfusion therapy may be initiated. Dissecting aneurysm is revealed by CT scan or MRI of the chest.

Other Useful Tests

1. CBC
2. Sedimentation rate (pneumonia, infarction)
3. Sputum smear and culture (pneumonia)
4. Bernstein test (reflux esophagitis)
5. Serum cardiac troponin levels [myocardial infarction (MI)]
6. d-Dimer testing (pulmonary embolism)
7. Esophagoscopy (reflux esophagitis)
8. X-ray of the spine (radiculopathy)
9. Echocardiogram (pericarditis)
10. 24-hour Holter monitoring (coronary insufficiency)
11. Gallbladder sonogram
12. Ambulatory pH monitoring (esophagitis)

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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