Chest pain
Chest pain usually results from disorders that affect thoracic or abdominal organs — the heart, pleurae, lungs, esophagus, rib cage, gallbladder, pancreas, or stomach. An important indicator of several acute and life-threatening cardiopulmonary and GI disorders, chest pain can also result from a musculoskeletal or hematologic disorder, anxiety, and drug therapy.
Chest pain can arise suddenly or gradually, and its cause may be difficult to ascertain initially. The pain can radiate to the arms, neck, jaw, or back. It can be steady or intermittent, mild or acute. It can range in character from a sharp shooting sensation to a feeling of heaviness, fullness, or even indigestion. It can be provoked or aggravated by stress, anxiety, exertion, deep breathing, or eating certain foods.
Ask the patient when his chest pain began. Did it develop suddenly or gradually? Is it more severe or frequent now than when it first started? Does anything relieve the pain? Does anything aggravate the pain? Ask the patient about associated symptoms. Sudden, severe chest pain requires prompt evaluation and treatment because it may herald a life-threatening disorder. See Managing severe chest pain and Associated disorder: Myocardial infarction, page 136.
History
If the chest pain isn’t severe, proceed with the history. Ask if the patient feels diffuse pain or can point to the painful area. Sometimes a patient won’t perceive the sensation he’s feeling as pain, so ask whether he has any discomfort radiating to his neck, jaw, arms, or back. If he does, ask him to describe it. Is it a dull, aching, pressurelike sensation? A sharp, stabbing, knifelike pain? Does he feel it on the surface or deep inside? Find out whether it’s constant or intermittent. If it’s intermittent, how long does it last? Ask if movement, exertion, breathing, position changes, or eating certain foods worsens or helps relieve the pain. Does anything in particular seem to bring it on?
Review the patient’s history for cardiac or pulmonary disease, chest trauma, intestinal disease, or sickle cell anemia. Find out which medications he’s taking, if any, and ask about recent dosage or schedule changes.
Physical assessment
Take the patient’s vital signs, noting tachypnea, fever, tachycardia, oxygen saturation, paradoxical pulse, and hypertension or hypotension. Also, look for jugular vein distention and peripheral edema. Observe the patient’s breathing pattern, and inspect his chest for asymmetrical expansion. Auscultate his lungs for pleural friction rub, crackles, rhonchi, wheezing, or diminished or absent breath sounds. Next, auscultate for murmurs, clicks, gallops, or pericardial friction rub. Palpate for lifts, heaves, thrills, gallops, tactile fremitus, and abdominal masses or tenderness.
Medical causes
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.
Special considerations
As needed, prepare the patient for cardiopulmonary studies, such as an electrocardiogram and a lung scan. Perform a venipuncture to collect a serum specimen for cardiac enzyme and other studies.
Pediatric pointers
Even children old enough to talk may have difficulty describing chest pain, so be alert for nonverbal clues, such as restlessness, facial grimaces, or holding of the painful area. Ask the child to point to the painful area and then to where the pain goes (to find out if it’s radiating). Determine the pain’s severity by asking the parents if the pain interferes with the child’s normal activities and behavior. Remember, a child may complain of chest pain in an attempt to get attention or to avoid attending school.
Geriatric pointers
Because older patients have a higher risk of developing life-threatening conditions (such as an MI, angina, and aortic dissection), you must carefully evaluate chest pain in these patients.
Patient counseling
Teach patients with coronary artery disease about the typical features of cardiac ischemia as well as the symptoms that should prompt them to seek medical attention. If the pain fails to disappear after sublingual nitroglycerin, lasts more than 20 minutes, or has a different pattern from the usual angina, the patient must be evaluated immediately.
Explain the purpose and procedure of each diagnostic test to the patient to help alleviate his anxiety. Also explain the purpose of any prescribed drugs, and make sure that the patient understands the dosage, schedule, and possible adverse effects.
Keep in mind that a patient with chest pain may deny his discomfort, so stress the importance of reporting symptoms to allow adjustment of his treatment.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Chest symptoms
Read excerpts from these other book chapters related to Chest symptoms:
Medical Books Excerpts
- CHEST PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- Chest pain
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Chest Pain
- "A Pocket Manual of Differential Diagnosis" (1999)
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- Chest pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Barrel chest
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Chest pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
- Chest pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
- Chest Pain
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Chest symptoms
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Chest Pain (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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